| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-tympanic_membrane.v0 |
|---|---|
| Concept | Examination of a tympanic membrane |
| Description | Findings observed during the physical examination of a tympanic membrane. |
| Use | Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of a tympanic membrane. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-external_auditory_canal or OBSERVATION.exam 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 - for example, the middle ear or the Tos or Sade classifications for retraction. 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 data not related to other parts of the ear such as the external ear or middle ear - use the specific archetypes, CLUSTER.exam-ear and CLUSTER.exam-middle_ear. 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 physical examination of a tympanic membrane. |
| References | Derived from: Examination of tympanic membrane, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2012 Sep 03. Available at: hhttp://dcm.nehta.org.au/ckm#showArchetype_1013.1.1086_17 (discontinued). |
| Copyright | © Northern Territory Department of Health (Australia), openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2012-09-03 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2012-09-03 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | in_development |
| UID | 05832949-775d-46ec-99f6-9f5b041d1fac |
| Language used | en |
| Citeable Identifier | 1246.145.2553 |
| Revision Number | 0.0.1-alpha |
| items | |
| System or structure examined | System or structure examined: Identification of the examined body system or anatomical structure. Coding of the system or structure examined with a terminology is preferred, where possible.
|
| Body site | Body site: Identification of the area of the body under examination. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant. |
| Structured body site | Structured body site: A structured description of the area of the body under examination. If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant. Include: openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| Examination findings | Examination findings: Structured details about the physical examination findings. Include: openEHR-EHR-CLUSTER.sade.v0 or openEHR-EHR-CLUSTER.exam-middle_ openEHR-EHR-CLUSTER.tos.v0 |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Include: openEHR-EHR-CLUSTER.media_ |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| View | View: Description about the examiner's view of the tympanic membrane.
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| Reason for occlusion | Reason for occlusion: Narrative description of the reason for occlusion of view of the tympanic membrane. For example: soft wax or a foreign body was present. |
| Appearance | Appearance: Category describing the appearance of the tympanic membrane. In most situations, this data element would only be recorded if the tympanic membrane is intact.
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| Colour | Colour: Description of the overall colour of the tympanic membrane. For example: red, bluish, or yellow. |
| Membrane intact? | Membrane intact?: Is the tympanic membrane intact?
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| Surface features | Surface features: Features observed on the surface of the tympanic membrane. May be coded with an external terminology, if desired, and be expressed as multiple occurrences. |
| Ventilation tube present? | Ventilation tube present?: Is a ventilation tube observed in the tympanic membrane? There is value in identifying the presence or absence of ventilation tubes in all examinations if ventilation tubes have previously been inserted. Please note: there is little value in recording the absence of ventilation tubes if they have never been inserted, unless it is not known if there has been previous insertion of ventilation tubes.
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| Ventilation tube placement | Ventilation tube placement: Observed placement of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal. This data element is redundant if ventilation tubes have been recorded as absent.
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| Location of tympanosclerosis | Location of tympanosclerosis: Description of the location of any tympanosclerosis observed on the tympanic membrane. May be coded with an external terminology, if desired, and be expressed as multiple occurrences for multiple sites. |
| Fluid level presence | Fluid level presence: Finding of a fluid level behind the tympanic membrane.
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| Fluid level description | Fluid level description: Narrative description of the fluid level and other related features observed behind the tympanic membrane. For example: presence of bubbles. |
| Mobility | Mobility: Description of mobility of the tympanic membrane. Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobility (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set.
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| Position of tympanic membrane | Position of tympanic membrane: Description of the position of the tympanic membrane.
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| Retraction description | Retraction description: Narrative description of the retraction of the tympanic membrane. |
| Perforation description | Perforation description: Narrative description of the perforation of the tympanic membrane. |
| Perforation size | Perforation size: Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks. Many clinicians record perforations between the well defined 'pinhole' and 'subtotal' perforations using a variety of terms with inconsistent usage and definitions, such as small, medium and large. 'Intermediate' has been proposed as a means to minimise inter-clinician variability for documenting the size of all perforations falling between the 'pinhole' and 'subtotal' definitions. If more detail is required, then measurement of the perforation should be recorded.
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| Intermediate estimation | Intermediate estimation: Qualification about the size of an intermediate perforation.
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| Length of perforation | Length of perforation: Direct measurement of the longest axis of the perforation. Usually measured from a photograph. Property: Length Units: >=0.0 mm |
| Width of perforation | Width of perforation: Direct measurement of the shortest axis of the perforation. Usually measured from a photograph. |
| Pars flaccida vs pars tensa? | Pars flaccida vs pars tensa?: Description of the region of the tympanic membrane perforation. To document explicitly whether the perforation is located in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant.
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| Marginal vs central? | Marginal vs central?: Location of the tympanic membrane perforation. To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant.
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| Anterior? | Anterior?: Is an anterior perforation present? To document the presence of perforation in the anterior portions of the pars tensa, which can be more difficult to manage than perforations elsewhere. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant.
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| Edge | Edge: Narrative description of the edge of the perforation. |
| Other contributors | 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) |
| Translators |
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