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openEHR-EHR-OBSERVATION.exam.v1

1 forms  
  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

Physical examination findings
Description

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

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0243095
Description
Description

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

Data type

text

Alias
UMLS CUI [1]
C0678257
Examination detail
Description

Structured details of the physical examination.

Data type

text

Alias
UMLS CUI [1]
C3898447
Interpretation
Description

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

Data type

text

Alias
UMLS CUI [1]
C0459471
Confounding factors
Description

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

Data type

text

Alias
UMLS CUI [1]
C0009673
Device Details
Description

Details about any device used during the physical examination.

Data type

text

Alias
UMLS CUI [1]
C0699733
Comment
Description

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

Data type

text

Alias
UMLS CUI [1]
C0947611
Position
Description

The body position of the subject during the examination.

Data type

text

Alias
UMLS CUI [1]
C0733755
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openEHR-EHR-OBSERVATION.exam.v1

1 forms
  1. StudyEvent: openEHR-EHR-OBSERVATION.exam.v1
    1. openEHR-EHR-OBSERVATION.exam.v1
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Physical examination findings
Item
Physical examination findings
text
C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Description
Item
Description
text
C0678257 (UMLS CUI [1])
Examination detail
Item
Examination detail
text
C3898447 (UMLS CUI [1])
Interpretation
Item
Interpretation
text
C0459471 (UMLS CUI [1])
Confounding factors
Item
Confounding factors
text
C0009673 (UMLS CUI [1])
Device Details
Item
Device Details
text
C0699733 (UMLS CUI [1])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Position
Item
Position
text
C0733755 (UMLS CUI [1])
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