| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-eye.v0 |
|---|---|
| Concept | Examination of an eye |
| Description | Findings observed during the physical examination of a single eye. |
| Use | Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of a single eye. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-eyes 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, CLUSTER.exam-retina or CLUSTER.exam-lens. 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_test_result. Not to be used to record the results of visual acuity testing - use OBSERVATION.visual_acuity-test-result. |
| Purpose | To record a narrative description and clinical interpretation of the findings observed during the physical examination of a single eye. |
| 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 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | in_development |
| UID | 47490335-07f8-4e1e-b8b8-3cdf53e79857 |
| Language used | en |
| Citeable Identifier | 1246.145.2708 |
| 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.exam-lens.v0 or openEHR-EHR-CLUSTER.exam-pupil.v0 or openEHR-EHR-CLUSTER.exam-aqueous_ |
| 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_ |
| Red reflex | Red reflex: Presence of the red reflex.
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| Squint | Squint: Presence of a squint.
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| Eye movement description | Eye movement description: Narrative description about the extraocular muscle function. |
| Movement detail | Movement detail: Detailed information about eye movement. |
| Direction of gaze | Direction of gaze: The direction of single eye movement.
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| Range | Range: Description of the range of movement in the identified direction of gaze. |
| Speed | Speed: Description of the speed of movement in the identified direction of gaze. |
| Smoothness | Smoothness: Description of the smoothness of movement in the identified direction of gaze. |
| 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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