ID

29603

Beschrijving

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/

Trefwoorden

Versies (1)
  1. 10-04-18 10-04-18 - Halim Ugurlu
Houder van rechten

openEHR Foundation

Geüploaded op

10 april 2018

DOI

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Licentie

Creative Commons BY-NC 3.0
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openEHR-EHR-CLUSTER.exam_pinna.v1

Engels

openEHR-EHR-CLUSTER.exam_pinna.v1

1 Formulieren  
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_pinna.v1
    1. openEHR-EHR-CLUSTER.exam_pinna.v1
openEHR-EHR-CLUSTER.exam_pinna.v1.xml
Beschrijving

openEHR-EHR-CLUSTER.exam_pinna.v1.xml

Examination of Pinna
Beschrijving

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

Datatype

text

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

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

Datatype

text

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

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

Datatype

text

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

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

Datatype

text

Alias
UMLS CUI [1]
C4086187
Multimedia representation
Beschrijving

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

Datatype

text

Alias
UMLS CUI [1]
C0681502
Pinna examined
Beschrijving

Identification of the pinna examined.

Datatype

text

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

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

Datatype

text

Alias
UMLS CUI [1]
C0334150
Site of scar
Beschrijving

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

Datatype

text

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

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

Datatype

text

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

Statement that no abnormality was detected on examination.

Datatype

boolean

Alias
UMLS CUI [1]
C0559229
Present?
Beschrijving

Is a scar present in the periaural region?

Datatype

text

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

Details to explicitly record that this examination was not performed.

Datatype

text

Alias
UMLS CUI [1,1]
C1272696
UMLS CUI [1,2]
C0031809
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Similar models

openEHR-EHR-CLUSTER.exam_pinna.v1

1 Formulieren
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_pinna.v1
    1. openEHR-EHR-CLUSTER.exam_pinna.v1
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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])
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