| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_faeces.v0 |
|---|---|
| Concept | Examination of faeces |
| Description | Findings observed during the examination of faeces. |
| Use | Use to record a narrative description, structured details and clinical interpretation about the findings observed during examination of faeces, which could occur during routine clinical observations or as part of a physical examination. This archetype has been designed to be used within:
It can also be used within other OBSERVATION or CLUSTER archetypes, 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 measurements of faecal output - use OBSERVATION.faecal_output for this purpose. Not to be used for recording the clinical history about bowel habits - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. |
| Purpose | To record the findings observed during the examination of faeces. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2018-11-16 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2018-11-16 |
| Other Details (Language Independent) |
|
| Keywords | faeces, poo |
| Lifecycle | in_development |
| UID | ae1161d1-05e2-4826-8a0e-e7dc523626f0 |
| Language used | en |
| Citeable Identifier | 1246.145.2723 |
| Revision Number | 0.0.2-alpha |
| items | |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the examination of faeces. |
| Colour | Colour: The overall colour of the faeces. |
| Blood presence | Blood presence: Narrative description about findings related to blood in or around the faecal specimen. |
| Consistency | Consistency: Narrative description about the firmness of the faeces. |
| Examination findings | Examination findings: Structured details about the examination findings of the faeces. 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 |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. |
| Comment | Comment: Additional narrative about the examination of faeces, 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 | Silje Ljosland Bakke, Nasjonal IKT HF, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom John Tore Valand, Haukeland Universitetssjukehus, Norway Heather Leslie, Atomica Informatics, Australia |
| Translators |