| ARCHETYPE ID | openEHR-EHR-CLUSTER.auscultation_bowel.v0 |
|---|---|
| Concept | Auscultation of bowel sounds |
| Description | Findings observed during the auscultation of bowel sounds. |
| Use | Use to record a description and clinical interpretation of findings observed during auscultation of bowel sounds in the abdomen or, in rare and abnormal circumstances, in the chest. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-abdomen, CLUSTER.exam-lung or OBSERVATION.exam archetypes, but can also be used within other ENTRY 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 - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign. |
| Purpose | To record a narrative description and clinical interpretation of the findings observed during the auscultation of bowel sounds in the abdomen or chest. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Keisha Barwise Organisation: openEHR Foundation Email: keisha.barwise@openehr.org Date originally authored: 2025-05-14 |
| Other Details Language | Author name: Keisha Barwise Organisation: openEHR Foundation Email: keisha.barwise@openehr.org Date originally authored: 2025-05-14 |
| Other Details (Language Independent) |
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| Keywords | bowel sounds, auscultation |
| Lifecycle | in_development |
| UID | 233b47e5-1295-4157-96b0-fe50f4055def |
| Language used | en |
| Citeable Identifier | 1246.145.2818 |
| Revision Number | 0.0.1-alpha |
| items | |
| Body site | Body site: Identification of the area of the body under examination. For example: right lower quadrant or left lower chest. 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 under examination. If the body site has been fully identified in the parent archetype in which this archetype is nested or in 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 auscultation findings. |
| Presence | Presence: The presence or absence of any bowel sounds heard on auscultation.
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| Intensity | Intensity: The relative volume or loudness of all bowel sounds compared to what is expected.
|
| Type | Type: The type or character of bowel sounds heard on auscultation. For example: Tinkling. |
| Frequency | Frequency: The assessment of the relative frequency of bowel sounds heard on auscultation.
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| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the auscultation findings at the body site. For example: 'No abnormality detected' or 'Decreased intestinal motility'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Comment | Comment: Additional narrative about the auscultation findings at the body site, not captured in other fields. |
| Other contributors | Heather Leslie CIO openEHR Foundation heather.leslie@openehr.org |
| Translators |