ARCHETYPE Examination of a lung (openEHR-EHR-CLUSTER.exam-lung.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-lung.v0
ConceptExamination of a lung
DescriptionFindings observed during the physical examination of a single lung, including specific parts of a lung.
UseUse to record a narrative description and clinical interpretation of the findings observed during the physical examination of a single lung, including identified parts of a lung. Use the 'Lung site' data element to identify a specific area of a lung, for example the right upper lobe or the lingula. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or CLUSTER.exam-chest archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Record the findings from the other lung in a second instance of this archetype within the same SLOT. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
MisuseNot to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
PurposeTo record a narrative description and clinical interpretation of the findings observed during the physical examination of a single lung, including identified parts of a lung.
ReferencesDerived from: <Add reference to original resource here>
Copyright© openEHR Foundation, HiGHmed
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-07-15
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2019-07-15
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=HiGHmed, references=Derived from: , current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.highmed, original_publisher=HiGHmed, custodian_namespace=org.highmed, MD5-CAM-1.0.1=1AE3EA698932A513CB598B7517598C07, build_uid=7009b839-5a6b-4691-9111-eaf98d832dda, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDae7e08fa-557b-4528-bb7f-797db7d2d42c
Language useden
Citeable Identifier1246.145.2317
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of a single lung, including specific parts of a lung., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
SB Bhattacharyya, Sudisa Consultancy Services, India
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Hilde Hollås, DIPS ASA, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Ivar Mehlum, Helse Bergen HF, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Lars Morgan Karlsen, DIPS ASA, Norway
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Jussara Rotzsch, UNB, Brazil
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia (openEHR Editor)
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Jon Tysdahl, Furst medlab AS, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor), originalLanguage=en, translators=
  • German: Maximilian Meixner, Berlin Institute of Health - BIH @ Charité, maximilian.meixner@bih-charite.de
  • Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF
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openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.3], code=at0.3, itemType=ELEMENT, level=1, text=Percussion note, description=Sound elicited by tapping on the chest wall., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal [Percussion note was normal.]
  • Dull [Percussion note was flat or dulled.]
  • Hyperresonant [Percussion note was louder and lower pitched than normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.7], code=at0.7, itemType=ELEMENT, level=1, text=Vocal resonance, description=Vibration intensity heard by a stethoscope on the chest wall with certain spoken words., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal [Vocal resonance was normal.]
  • Increased [Vocal resonance was increased, compared to normal.]
  • Reduced [Vocal resonance was decreased, compared to normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.11], code=at0.11, itemType=ELEMENT, level=1, text=Vocal fremitus, description=Vibration intensity felt by the hand on the chest wall from certain spoken words., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal [Vocal fremitus was normal.]
  • Increased [Vocal fremitus was increased, compared to normal.]
  • Reduced [Vocal fremitus was decreased, compared to normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004.1], code=at0004.1, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam-auscultation-breath_sounds.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations or
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  • Dull [Percussion note was flat or dulled.]
  • Hyperresonant [Percussion note was louder and lower pitched than normal.]
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  • Normal [Vocal resonance was normal.]
  • Increased [Vocal resonance was increased, compared to normal.]
  • Reduced [Vocal resonance was decreased, compared to normal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.11], code=at0.11, itemType=ELEMENT, level=1, text=Vocal fremitus, description=Vibration intensity felt by the hand on the chest wall from certain spoken words., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal [Vocal fremitus was normal.]
  • Increased [Vocal fremitus was increased, compared to normal.]
  • Reduced [Vocal fremitus was decreased, compared to normal.]
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