ID

23635

Descripción

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.

Palabras clave

  1. 10/7/17 10/7/17 - Martin Dugas
  2. 10/7/17 10/7/17 - Martin Dugas
Subido en

10 de julio de 2017

DOI

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Licencia

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
Descripción

openEHR-EHR-OBSERVATION.exam.v1.xml

Physical examination findings
Descripción

Findings observed during the physical examination of a subject of care.

Tipo de datos

text

Event Series
Descripción

@ internal @

Tipo de datos

text

Any event
Descripción

Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.

Tipo de datos

text

Tree
Descripción

@ internal @

Tipo de datos

text

Description
Descripción

Narrative description of the overall findings observed during a physical examination of a patient.

Tipo de datos

text

Examination detail
Descripción

Structured details of the physical examination.

Tipo de datos

text

Interpretation
Descripción

Single word, phrase or brief description which represents the clinical meaning and significance of the physical examination findings.

Tipo de datos

text

Tree
Descripción

@ internal @

Tipo de datos

text

Confounding factors
Descripción

Description of any incidental factors that may have contributed to the physical examination findings.

Tipo de datos

text

Tree
Descripción

@ internal @

Tipo de datos

text

Device Details
Descripción

Details about any device used during the physical examination.

Tipo de datos

text

Comment
Descripción

Additional narrative about the overall physical examination findings not captured in other fields.

Tipo de datos

text

Extension
Descripción

Additional information required to capture local content or to align with other reference models/formalisms.

Tipo de datos

text

Position
Descripción

The body position of the subject during the examination.

Tipo de datos

text

Similar models

openEHR-EHR-OBSERVATION.exam.v1

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

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