| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_tendon_reflexes.v0 |
|---|---|
| Concept | Examination of deep tendon reflexes |
| Description | Findings observed during the physical examination of deep tendon reflexes in the limbs. |
| Use | Use to record a description of the overall findings observed during the physical examination of deep tendon reflexes. This initial draft archetype consists only of the core examination pattern data elements (as per CLUSTER.exam_pattern) and will likely be expanded further over time as specific clinical requirements are identified. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_nervous_system archetype, but can also be used within the OBSERVATION.exam and 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 the clinical history about deep tendon reflexes - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record the response to Masseter reflex (Jaw jerk). Use CLUSTER.exam_cranial_nerves for this purpose. Not to be used to record the respons to the Plantar reflex (Babinski response/sign). Use CLUSTER.exam.foot for this purpose. |
| Purpose | For recording a description and clinical interpretation of the findings observed during the physical examination of deep tendon reflexes in the limbs. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2018-09-12 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2018-09-12 |
| Other Details (Language Independent) |
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| Keywords | examination, nervous system, reflexes, tendon |
| Lifecycle | in_development |
| UID | 52c3c495-8736-4e6d-85b9-613095d12883 |
| Language used | en |
| Citeable Identifier | 1246.145.2794 |
| Revision Number | 0.0.2-alpha |
| items | |
| 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. Allowed values: {true} |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| (Per reflex) | (Per reflex): Details per reflex. Runtime name constraint:
|
| Response | Response: Strength of the reflex response.
|
| With recruitment? | With recruitment?: Record as true if muscle recruitment was used to accentuate the response. Allowed values: {true} |
| Comment | Comment: Additional narrative about the reflex response findings, not captured in other fields. |
| 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 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 | Silje Ljosland Bakke, Nasjonal IKT HF, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom John Tore Valand, Haukeland Universitetssjukehus, Norway |
| Translators |