| ARCHETYPE ID | openEHR-EHR-CLUSTER.exclusion_exam.v1 |
| Concept | Exclusion of examination |
| Description | Positive statement to record that a physical examination or clinical test was not performed. |
| Use | Use to record that a physical examination or clinical test was not performed, with an optional statement about the reason for the non-performance. This archetype has been designed to be used to allow recording of 'no examination was done' at multiple levels of the examination process. It will never be used as a stand-alone archetype but always inside an examination archetype that provides the context for the examination being performed. For example, insertion of this archetype into the Examination Detail' SLOT within OBSERVATION.exam allows for recording that no physical examination was performed. Similarly, insertion of this archetype into the Details SLOT of any examination-related CLUSTER archetype, such as CLUSTER.exam_eye_pupil, allows recording that no physical examination was performed only for examination of a specified pupil, perhaps because a facial injury prevented the pupil being visualised. This archetype may also be used within other OBSERVATION, or relevent CLUSTER, archetypes to allow recording of the inability to test or measure other clinical findings. For example: OBSERVATION.audiogram or OBSERVATION.cgas. In particular, this archetype has specifically been designed to avoid the need to use flags or terminology to express negation about a record of physical examination or clinical findings within the health record. It is reasonable to assume that if the examination or clinical assessment was partially performed, then only data about the component successfully performed will be recorded. |
| Misuse | Not to be used to record the details about clinical findings observed on physical examination or during clinical testing. Use specific archetypes for these purposes. Not to be used to record the exclusion or absence of adverse reactions, family history, medication use, procedures, problems or diagnoses - use EVALUATION.exclusion_global or EVALUATION.exclusion_specific for this purpose. |
| Purpose | To record that a physical examination or clinical test was not performed. |
| References | Exclusion of examination, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-22]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1383 |
| Copyright | © Australian Digital Health Agency, openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-01-14 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2015-01-14 |
| OtherDetails Language Independent | {custodian_organisation=openEHR Foundation, references=Exclusion of examination, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-22]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.1383, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=2DCECCDEA74C4AD5B9B0F6087F57BE61, build_uid=9ebf8286-e78c-40e5-bb9f-01b54114b662, revision=1.1.1} |
| Keywords | exclusion, exam, examination, done, performed |
| Lifecycle | published |
| UID | 6c9ede6d-923b-4b22-9005-3fdf4e853a0c |
| Language used | en |
| Citeable Identifier | 1246.145.572 |
| Revision Number | 1.1.1 |
| All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Positive statement to record that a physical examination or clinical test was not performed., archetypeConceptComment=null, otherContributors=Vebjoern Arntzen, Oslo university hospital, Norway Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, National ICT Norway, Norway (openEHR Editor) Lars Bitsch-Larsen, Haukeland University hospital, Norway Heather Grain, Llewelyn Grain Informatics, Australia Evelyn Hovenga, EJSH Consulting, Australia Lars Karlsen, DIPS ASA, Norway Heather Leslie, Ocean Informatics, Australia (openEHR Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Bjoern Naess, DIPS ASA, Norway Andrej Orel, Marand d.o.o., Slovenia, originalLanguage=en, translators= , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={source=[], context=[], details=[], credentials=[], events=[], description=[], identities=[], protocol=[], content=[], activities=[], state=[], contacts=[], other_participations=[], target=[], provider=[], ism_transition=[], capabilities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Examination not done, description=Statement to explicity record that the examination was not performed., comment=Record as True if the examination was not performed., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Reason, description=Reason for the 'not done' statement., comment=For example: patient factors, equipment factors, time constraints., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], data=[], relationships=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Examination not done, description=Statement to explicity record that the examination was not performed., comment=Record as True if the examination was not performed., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Reason, description=Reason for the 'not done' statement., comment=For example: patient factors, equipment factors, time constraints., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |