ID

23498

Description

Derived from www.openehr.org Use to record in a clinical examination that the physical examination, or a specified part of the physical examination, 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. 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 within the health record. It is reasonable to assume that if the examination was partially performed, then only data about the examination performed will be recorded. If the examination was difficult to perform, for example an uncooperative patient, then this information can be included in the overall 'Confounding Factors' data element in the root OBSERVATION.exam archetype or in the 'Comment' data element in each examination CLUSTER archetype.

Link

www.openehr.org

Keywords

Versions (2)

1. 7/8/17 7/8/17 - Martin Dugas
2. 7/8/17 7/8/17 - Martin Dugas

Uploaded on

July 8, 2017

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