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openEHR-EHR-CLUSTER.exam_skin.v0

1 Formulare  
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_skin.v0
    1. openEHR-EHR-CLUSTER.exam_skin.v0
openEHR-EHR-CLUSTER.exam_skin.v0.xml
Beschreibung

openEHR-EHR-CLUSTER.exam_skin.v0.xml

Examination of skin
Beschreibung

Findings observed during the physical examination of an area of skin.

Datentyp

text

Alias
UMLS CUI [1]
C0437750
Body site
Beschreibung

Identification of the area of skin under examination.

Datentyp

text

Alias
UMLS CUI [1]
C1515974
No abnormality detected
Beschreibung

Statement that no abnormality was detected (NAD) on physical examination.

Datentyp

boolean

Alias
UMLS CUI [1]
C0559229
Clinical description
Beschreibung

Narrative description of the overall findings observed during the skin examination.

Datentyp

text

Alias
UMLS CUI [1,1]
C0678257
UMLS CUI [1,2]
C0205210
Examination findings
Beschreibung

Structured details about one or more specific findings on physical examination of the identified skin site.

Datentyp

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0243095
Multimedia representation
Beschreibung

Digital image, video or diagram representing the physical examination findings.

Datentyp

text

Alias
UMLS CUI [1]
C0376478
Clinical interpretation
Beschreibung

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

Datentyp

text

Alias
UMLS CUI [1]
C4086187
Comment
Beschreibung

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

Datentyp

text

Alias
UMLS CUI [1]
C0947611
Examination 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
Structured body site
Beschreibung

A structured description of the area of skin under examination.

Datentyp

text

Alias
UMLS CUI [1]
C1515974
Finding summary
Beschreibung

Summary information about findings on the skin at the identified body site.

Datentyp

text

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C0242482
Finding
Beschreibung

Identification of the clinical finding, by name or category.

Datentyp

text

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C0205396
Presence
Beschreibung

The presence or absence of the specified finding.

Datentyp

text

Alias
UMLS CUI [1,1]
C0012634
UMLS CUI [1,2]
C0150312
Clinical description
Beschreibung

Narrative description about the specified finding.

Datentyp

text

Alias
UMLS CUI [1,1]
C0678257
UMLS CUI [1,2]
C0205210
Number
Beschreibung

The number of the specified finding observed in the identified body site.

Datentyp

integer

Alias
UMLS CUI [1]
C0243095
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Ähnliche Modelle

openEHR-EHR-CLUSTER.exam_skin.v0

1 Formulare
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_skin.v0
    1. openEHR-EHR-CLUSTER.exam_skin.v0
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Examination of skin
Item
Examination of skin
text
C0437750 (UMLS CUI [1])
Body site
Item
Body site
text
C1515974 (UMLS CUI [1])
No abnormality detected
Item
No abnormality detected
boolean
C0559229 (UMLS CUI [1])
Clinical description
Item
Clinical description
text
C0678257 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Examination findings
Item
Examination findings
text
C0031809 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Multimedia representation
Item
Multimedia representation
text
C0376478 (UMLS CUI [1])
Clinical interpretation
Item
Clinical interpretation
text
C4086187 (UMLS CUI [1])
Comment
Item
Comment
text
C0947611 (UMLS CUI [1])
Examination not done
Item
Examination not done
text
C1272696 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Structured body site
Item
Structured body site
text
C1515974 (UMLS CUI [1])
Finding summary
Item
Finding summary
text
C0243095 (UMLS CUI [1,1])
C0242482 (UMLS CUI [1,2])
Finding
Item
Finding
text
C0243095 (UMLS CUI [1,1])
C0205396 (UMLS CUI [1,2])
Item
Presence
text
C0012634 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
Presence
Code List
Presence
CL Item
Present (1)
CL Item
Absent (2)
CL Item
Indeterminate (3)
Clinical description
Item
Clinical description
text
C0678257 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Number
Item
Number
integer
C0243095 (UMLS CUI [1])
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