| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-hip_joint.v0 |
|---|---|
| Concept | Physical examination of a hip joint |
| Description | Findings observed during the physical examination of a hip joint. |
| Use | Use to record the observed findings during the physical examination of a hip joint. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the "Procedure detail" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Interpretation of the findings, for example 'No abnormality detected', can be recorded using the 'Clinical interpretation' data element. 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. The intended scope for this archetype is to eventually record all detailed findings on physical examination of the hip joint. It is anticipated that further data elements may be added as requirements are identified and confirmed. 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 for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose. |
| Purpose | To record the findings observed during the physical examination of a hip joint. |
| References | Avgrenet fra: Examination findings, Published archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2022-03-29]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.6153 Muscle Strength Testing [Internet]. Physiopedia [cited: 2023-04-13]. Available from: https://www.physio-pedia.com/Muscle_Strength_Testing. Hip Examination [Internet]. Pysiopedia [cited: 2023-04-13]. Available from https://www.physio-pedia.com/Hip_Examination. |
| Copyright | © Nasjonal IKT HF, openEHR Foundation |
| Authors | Author name: Hanne Marte Bårholm Organisation: Helse Vest IKT AS Email: hanne.marte.sandal.barholm@helse-vest-ikt.no Date originally authored: 2023-03-15 |
| Other Details Language | Author name: Hanne Marte Bårholm Organisation: Helse Vest IKT AS Email: hanne.marte.sandal.barholm@helse-vest-ikt.no Date originally authored: 2023-03-15 |
| Other Details (Language Independent) |
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| Keywords | articulatio coxae, osteoarthritis |
| Lifecycle | in_development |
| UID | a36d9a9c-1ec0-4225-9945-148cfd66ce10 |
| Language used | en |
| Citeable Identifier | 1246.145.2825 |
| 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: 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_ |
| Other contributors | Stein Arne Rimehaug, Sunnaas sykehus, Norway Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) Ivar Berge, Oslo Universitetssykehus, Norway SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India Heather Grain, Llewelyn Grain Informatics, Australia Ronald Krawec, Alberta Health Services, Canada Jörgen Kuylenstierna, eWeave AB, Sweden Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Michael Lutz, BITsoft, Germany Hanne Marte Bårholm, Helse Vest IKT AS Svenne Naumann, Finnmarkssykehuset, Norway Mikael Nyström, Cambio Healthcare Systems AB, Sweden Terje Sagmyr, Helse Vest IKT, Norway Bodil Salvesen, Barneklinikken Haukeland Universitetssykehus, Norway Natalia Strauch, Medizinische Hochschule Hannover, Germany Norwegian Review Summary, Norwegian Public Hospitals, Norway Kanthan Theivendran, NHS, United Kingdom Anders Thurin, VGR, Sweden John Tore Valand, Helse Vest IKT, Norway (openEHR Editor) |
| Translators |
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