ID

29603

Beschreibung

http://openehr.org/ckm/ Use to record findings observed during the physical examination of a specified pinna and associated scars. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. Specifically designed to be used within the CLUSTER.exam_ears archetype, but may be used within any clinically appropriate ENTRY or CLUSTER archetype related to physical examination of the ear.

Link

http://openehr.org/ckm/

Stichworte

Versionen (1)
  1. 10.04.18 10.04.18 - Halim Ugurlu
Rechteinhaber

openEHR Foundation

Hochgeladen am

10. April 2018

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

openEHR-EHR-CLUSTER.exam_pinna.v1

Englisch

openEHR-EHR-CLUSTER.exam_pinna.v1

1 Formulare  
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_pinna.v1
    1. openEHR-EHR-CLUSTER.exam_pinna.v1
openEHR-EHR-CLUSTER.exam_pinna.v1.xml
Beschreibung

openEHR-EHR-CLUSTER.exam_pinna.v1.xml

Examination of Pinna
Beschreibung

Findings observed during the physical examination of the external structure of the ears, and scars in the adjacent periauricular region.

Datentyp

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0013453
Clinical description
Beschreibung

Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position.

Datentyp

text

Alias
UMLS CUI [1,1]
C0678257
UMLS CUI [1,2]
C0205210
Pinna details
Beschreibung

Structured details of physical examination findings for the specific parts of the identified pinna or related structures.

Datentyp

text

Alias
UMLS CUI [1,1]
C1047272
UMLS CUI [1,2]
C1522508
Clinical interpretation
Beschreibung

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

Datentyp

text

Alias
UMLS CUI [1]
C4086187
Multimedia representation
Beschreibung

Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure.

Datentyp

text

Alias
UMLS CUI [1]
C0681502
Pinna examined
Beschreibung

Identification of the pinna examined.

Datentyp

text

Alias
UMLS CUI [1,1]
C0013453
UMLS CUI [1,2]
C0031809
Surgical scar
Beschreibung

Findings about surgical scars identified on, or related to the identified pinna.

Datentyp

text

Alias
UMLS CUI [1]
C0334150
Site of scar
Beschreibung

Identification of the the specific anatomical structure of the pinna or related anatomical region examined.

Datentyp

text

Alias
UMLS CUI [1,1]
C0449695
UMLS CUI [1,2]
C0241158
Scar description
Beschreibung

Narrative description of the scar, including likely aetiology and state of healing.

Datentyp

text

Alias
UMLS CUI [1,1]
C0241158
UMLS CUI [1,2]
C0678257
No abnormality detected
Beschreibung

Statement that no abnormality was detected on examination.

Datentyp

boolean

Alias
UMLS CUI [1]
C0559229
Present?
Beschreibung

Is a scar present in the periaural region?

Datentyp

text

Alias
UMLS CUI [1,1]
C0241158
UMLS CUI [1,2]
C0150312
Exam not done
Beschreibung

Details to explicitly record that this examination was not performed.

Datentyp

text

Alias
UMLS CUI [1,1]
C1272696
UMLS CUI [1,2]
C0031809
Zum Seitenanfang zurückkehren

Ähnliche Modelle

openEHR-EHR-CLUSTER.exam_pinna.v1

1 Formulare
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_pinna.v1
    1. openEHR-EHR-CLUSTER.exam_pinna.v1
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Examination of Pinna
Item
Examination of Pinna
text
C0031809 (UMLS CUI [1,1])
C0013453 (UMLS CUI [1,2])
Clinical description
Item
Clinical description
text
C0678257 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Pinna details
Item
Pinna details
text
C1047272 (UMLS CUI [1,1])
C1522508 (UMLS CUI [1,2])
Clinical interpretation
Item
Clinical interpretation
text
C4086187 (UMLS CUI [1])
Multimedia representation
Item
Multimedia representation
text
C0681502 (UMLS CUI [1])
Item
Pinna examined
text
C0013453 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Pinna examined
Code List
Pinna examined
CL Item
Left pinna (1)
CL Item
Right pinna (2)
Surgical scar
Item
Surgical scar
text
C0334150 (UMLS CUI [1])
Site of scar
Item
Site of scar
text
C0449695 (UMLS CUI [1,1])
C0241158 (UMLS CUI [1,2])
Scar description
Item
Scar description
text
C0241158 (UMLS CUI [1,1])
C0678257 (UMLS CUI [1,2])
No abnormality detected
Item
No abnormality detected
boolean
C0559229 (UMLS CUI [1])
Item
Present?
text
C0241158 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
Present?
Code List
Present?
CL Item
Present (1)
CL Item
Absent (2)
Exam not done
Item
Exam not done
text
C1272696 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video