| ARCHETYPE ID | openEHR-EHR-CLUSTER.skin_sensation.v0 |
|---|---|
| Concept | Skin sensation |
| Description | A physical feeling or perception resulting from a stimulus or comes into contact with the skin. |
| Use | Use to record the results of skin sensation testing on an individual by the application of a stimulus. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-skin, CLUSTER.exam-cutaneous_nerve or CLUSTER.exam-nerve_root archetypes which provide the context for the structure or system that is being examined. This archetype can also be used within other ENTRY or CLUSTER archetypes that provide relevant system or structure context, where clinically appropriate. 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 the results of skin sensation testing on an individual by the application of a stimulus. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2019-07-26 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2019-07-26 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | in_development |
| UID | 542dfef2-3dcc-4fa8-b78d-6f87c679fdd8 |
| Language used | en |
| Citeable Identifier | 1246.145.2622 |
| 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, nerve or dermatome under examination. If the body site has been fully identified in the parent archetype in which this archetype is nested, this data element becomes redundant. |
| Structured body site | Structured body site: A structured description of the area of the body, nerve or dermatome 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_ |
| No abnormality detected | No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination. 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'. Allowed values: {true} |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the skin sensation examination. |
| Light touch | Light touch: Findings observed during testing of light touch.
|
| Vibration | Vibration: Findings observed during testing of vibration.
|
| Pain | Pain: Findings observed during testing of pain.
|
| Temperature | Temperature: Findings observed during testing of temperature.
|
| Touch localisation | Touch localisation: Findings observed during testing of touch localisation.
|
| Examination findings | Examination findings: Structured details about the physical examination findings. Include: All not explicitly excluded archetypes |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Include: openEHR-EHR-CLUSTER.multimedia.v1 and specialisations or openEHR-EHR-CLUSTER.multimedia.v0 and specialisations |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the sensation findings. 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_ |
| Other contributors | |
| Translators |