ID

23635

Description

Use to record details about findings on physical examination of the subject of care. This may include a narrative description of the findings, a framework in which to nest detailed CLUSTER examination archetypes, and a clinical interpretation of the findings. Examples of detailed CLUSTER examination archetypes include those that describe inspection, palpation, auscultation, percussion and movement of body systems or anatomical structures, such as CLUSTER.exam_pupils. Narrative descriptions of clinical findings from existing clinical systems may be captured using the 'Description' data element. Clinicians may sometimes want to record a summative phrase such as 'chronic otitis media' as an Interpretation of the physical examination. In the context of the physical examination archetype this should only be understood as 'physical signs are consistent with chronic otitis media'. While the summative phrase may appear to represent a diagnosis, safe and consistent querying requires a diagnosis to be recorded using the EVALUATION.problem_diagnosis archetype, even if the phrases are identical.

Mots-clés

  1. 10/07/2017 10/07/2017 - Martin Dugas
  2. 10/07/2017 10/07/2017 - Martin Dugas
Téléchargé le

10 juillet 2017

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0

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Physical examination findings

openEHR-EHR-OBSERVATION.exam.v1

  1. StudyEvent: openEHR-EHR-OBSERVATION.exam.v1
    1. openEHR-EHR-OBSERVATION.exam.v1
openEHR-EHR-OBSERVATION.exam.v1.xml
Description

openEHR-EHR-OBSERVATION.exam.v1.xml

Ugotovitve pregleda
Description

Za dokumentiranje ugotovitev/znakov fizikalnega pregleda subjekta

Type de données

text

Event Series
Description

Event Series

Type de données

text

Any event
Description

Any event

Type de données

text

Tree
Description

Tree

Type de données

text

Klinični opis
Description

Beleženje ugotovljenih dejstev pri pregledu

Type de données

text

Examination detail
Description

Examination detail

Type de données

text

Interpretation
Description

Interpretation

Type de données

text

Tree
Description

Tree

Type de données

text

Confounding factors
Description

Confounding factors

Type de données

text

Tree
Description

Tree

Type de données

text

Device Details
Description

Device Details

Type de données

text

Comment
Description

Comment

Type de données

text

Extension
Description

Extension

Type de données

text

Position
Description

Position

Type de données

text

Similar models

openEHR-EHR-OBSERVATION.exam.v1

  1. StudyEvent: openEHR-EHR-OBSERVATION.exam.v1
    1. openEHR-EHR-OBSERVATION.exam.v1
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Physical examination findings
Item
Ugotovitve pregleda
text
Event Series
Item
text
Any event
Item
text
Tree
Item
text
Description
Item
Klinični opis
text
Examination detail
Item
text
Interpretation
Item
text
Tree
Item
text
Confounding factors
Item
text
Tree
Item
text
Device Details
Item
text
Comment
Item
text
Extension
Item
text
Position
Item
text

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