| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-cranial_nerves.v0 |
|---|---|
| Concept | Examination of cranial nerves |
| Description | Findings observed during the physical examination of the cranial nerves. |
| Use | Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or CLUSTER.exam-nervous_system archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes for each cranial nerve can be nested in the appropriate SLOTs and other 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. Not to be used to record the results of visual field testing - use OBSERVATION.visual_field_measurement for this purpose. Not to be used to record the results of visual acuity testing - use OBSERVATION.visual_acuity for this purpose. |
| Purpose | To record a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-24 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2015-06-24 |
| Other Details (Language Independent) |
|
| Keywords | |
| Lifecycle | in_development |
| UID | c189c249-abad-40de-908c-5c3c39308aef |
| Language used | en |
| Citeable Identifier | 1246.145.2685 |
| 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. For example examination of a specific area of skin. 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: All not explicitly excluded archetypes |
| 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_ |
| I description | I description: Narrative description about findings on examination of the olfactory nerve. For example: summary about smell testing. |
| I details | I details: Details about function of the olfactory nerve. Include: openEHR-EHR-CLUSTER.exclusion_ |
| II description | II description: Narrative description about findings on examination of the optic nerve. |
| II details | II details: Details about the function of the optic nerve. Include: openEHR-EHR-CLUSTER.exclusion_ |
| III, IV & VI description | III, IV & VI description: Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves. |
| III, IV & VI details | III, IV & VI details: Details about the function of the oculomotor, trochlear and abducens nerves. Include: openEHR-EHR-CLUSTER.exclusion_ openEHR-EHR-CLUSTER.exam-pupil.v0 |
| V description | V description: Narrative description about findings on examination of the trigeminal nerve. |
| Corneal reflex | Corneal reflex: The presence of the corneal reflex. Also known as the 'blink reflex'.
|
| Jaw jerk | Jaw jerk: The presence of the jaw jerk.
|
| V details | V details: Details about the function of the trigeminal nerve. Include: openEHR-EHR-CLUSTER.exclusion_ |
| VII description | VII description: Narrative description about findings on examination of the facial nerve. |
| VII details | VII details: Details about the function of the facial nerve. Include: openEHR-EHR-CLUSTER.exclusion_ openEHR-EHR-CLUSTER.exam-face.v0 |
| VIII description | VIII description: Narrative description about findings on examination of the vestibulococchlear nerve. |
| VIII details | VIII details: Details about the function of the vestibulococchlear nerve. Include: openEHR-EHR-CLUSTER.exclusion_ |
| IX & X description | IX & X description: Narrative description about findings on examination of the glossopharyngeal and vagus nerves. |
| Gag reflex | Gag reflex: The presence of the pharyngeal, or gag, reflex.
|
| IX & X details | IX & X details: Details about the function of the glossopharyngeal and vagus nerves. Include: openEHR-EHR-CLUSTER.exclusion_ openEHR-EHR-CLUSTER.exam-throat.v0 |
| XI description | XI description: Narrative description about findings on examination of the accessory nerve. |
| XI details | XI details: Details about the function of the accessory nerve. Include: openEHR-EHR-CLUSTER.exclusion_ |
| XII description | XII description: Narrative description about findings on examination of the hypoglossal nerve. |
| XII details | XII details: Details about the function of the hypoglossal nerve. Include: openEHR-EHR-CLUSTER.exclusion_ openEHR-EHR-CLUSTER.exam-tongue.v0 |
| 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 |
|