ID

23636

Description

Derived from www.openehr.org . 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.

Link

www.openehr.org

Keywords

  1. 7/10/17 7/10/17 - Martin Dugas
  2. 7/10/17 7/10/17 - Martin Dugas
Uploaded on

July 10, 2017

DOI

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License

Creative Commons BY-SA 3.0

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Physical examination findings (EHR Archetype)

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

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

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)
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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