ARCHETYPE Examination of abdomen (openEHR-EHR-CLUSTER.exam_abdomen.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_abdomen.v0
ConceptExamination of abdomen
DescriptionFindings observed during the physical examination of the abdomen.
UseUse to record a narrative description of the overall findings observed during the physical examination of the abdomen. 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 detail' SLOT within the OBSERVATION.exam archetype, but can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. 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.
MisuseNot to be used for recording data not related to the physical examination of the abdomen. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure or OBSERVATION.imaging_exam.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the physical examination of the abdomen.
ReferencesDerived from: <Add reference to original resource here>
Copyright© openEHR Foundation, HiGHmed
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-06-22
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-06-22
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=HiGHmed, references=Derived from: , current_contact=Heather Leslie, Atomica Informatics, original_namespace=org.highmed, original_publisher=HiGHmed, custodian_namespace=org.highmed, MD5-CAM-1.0.1=4870C4FC89A9CDFF84389882A8F6527A, build_uid=add1c5f2-deb5-4bec-9fa2-aa664db3f8f6, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDac3d8991-af9d-42b8-88b9-0da331c64b4a
Language useden
Citeable Identifier1246.145.674
Revision Number0.0.1-alpha
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Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
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