ARCHETYPE Auscultation of breath sounds (openEHR-EHR-CLUSTER.exam-auscultation-breath_sounds.v0)

Name: Auscultation of breath sounds
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.exam-auscultation-breath_sounds.v0
Concept	Auscultation of breath sounds
Description	Findings observed during the auscultation of breath sounds in the chest or abdomen.
Use	Use to record a narrative description and clinical interpretation of the findings observed during the auscultation of breath sounds in the chest or abdomen. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam, CLUSTER.exam-lung or CLUSTER.exam-abdomen archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. 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.
Misuse	Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
Purpose	To record a narrative description and clinical interpretation of the findings observed during the auscultation of breath sounds in the chest or abdomen.
References
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-23
Other Details Language	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-23
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=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=7BA0C4B6525C26FF3F3F934A5A486553, build_uid=e3990962-bee7-4217-8acd-f8f74c76b4c2, 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
Lifecycle	in_development
UID	b3dc06e6-f78d-4a9e-a452-d16a4ea3aab3
Language used	en
Citeable Identifier	1246.145.2381
Revision Number	0.0.1-alpha
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the auscultation of breath sounds in the chest or abdomen., 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 , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={relationships=[], source=[], capabilities=[], activities=[], details=[], context=[], ism_transition=[], other_participations=[], data=[], credentials=[], target=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001.0.1], code=at0001.0.1, itemType=ELEMENT, level=1, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0.0.1::Chest [The chest is examined.] [SNOMED-CT::51185008 \| Thoracic structure] at0.0.2::Abdomen [The abdomen is examined.] [SNOMED-CT::113345001 \| Abdomen] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=Body site, description=Identification of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured description of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=0.., occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:* 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[at0.0.3], code=at0.0.3, itemType=ELEMENT, level=1, text=Presence, description=The presence of breath sounds., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0.0.4::Present [Breath sounds are heard.] at0.0.5::Absent [Breath sounds are not heard.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002.0.1], code=at0002.0.1, 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. 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subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0.0.17::Present [The abnormal breath sound is present.] at0.0.18::Absent [The abnormal breath sound is not present.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.8]/items[at0.0.19], code=at0.0.19, itemType=ELEMENT, level=2, text=Clinical description, description=Narrative description about the abnormal breath sound., 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[at0004], code=at0004, 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, 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