ID

23508

Beskrivning

Derived from www.openehr.org . Use to record structured and consistent details about a single identified physical site on, or within, the human body by describing its location in relation to identified macroscopic anatomical landmarks. It may be necessary to describe the single physical location using more than one relative location - for example, 2 cm inferior to 'landmark A' AND 3 cm medial to 'landmark B'. In practice, some archetypes carry a single data element for carrying a simple description of body site - for example, OBSERVATION.blood_pressure and CLUSTER.symptom when describing ear pain. In this situation, where the value set is predictable and simple to define, this single data element is a very accurate and pragmatic way to record the site in the body and to query at a later date. However in the situation where the anatomical location is not well defined or needs to be determined at run-time, it may be more flexible to use this structured archetype. This archetype is specifically designed to be used within the context of any appropriate ENTRY or CLUSTER archetypes which supply the context of the identified body site, including insertion within the CLUSTER.anatomical_location if 'Body site name' or other data elements are also required. Clinical use cases: - 5 cm inferior to the left tibial tuberosity - 2 cm medial to the right nipple - medial aspect of R great toe nail. In the situation where the CLUSTER.anatomical_location can only be used to name a large and/or non-specific body part, the use of this archetype within the 'Alternative Structure' SLOT will support recording of a more precise location - for example, 2 cm anterior to the cubital fossa of the left forearm or 4 cm below R costal margin on the chest wall in the mid-clavicular line.

Länk

www.openehr.org

Nyckelord

Versioner (2)

1. 2017-07-08 2017-07-08 - Martin Dugas
2. 2017-07-08 2017-07-08 - Martin Dugas

Uppladdad den

8 juli 2017

DOI

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Licens