ID

29604

Description

Use to record a description of the overall findings observed during the physical examination of an area of skin. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within many of the CLUSTER archetypes for examination of various regions or anatomical structures - for example, CLUSTER.exam_abdomen or CLUSTER.exam_breast - but can also be used within the OBSERVATION.exam. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. 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.

Mots-clés

Versions (1)
  1. 10/04/2018 10/04/2018 - Halim Ugurlu
Détendeur de droits

openEHR Foundation

Téléchargé le

10 avril 2018

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0
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openEHR-EHR-CLUSTER.exam_skin.v0

Anglais Norvégien

openEHR-EHR-CLUSTER.exam_skin.v0

1 Formulaires  
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_skin.v0
    1. openEHR-EHR-CLUSTER.exam_skin.v0
openEHR-EHR-CLUSTER.exam_skin.v0.xml
Description

openEHR-EHR-CLUSTER.exam_skin.v0.xml

Examination of skin
Description

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

Type de données

text

Alias
UMLS CUI [1]
C0437750
Body site
Description

Identification of the area of skin under examination.

Type de données

text

Alias
UMLS CUI [1]
C1515974
No abnormality detected
Description

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

Type de données

boolean

Alias
UMLS CUI [1]
C0559229
Clinical description
Description

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

Type de données

text

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

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

Type de données

text

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

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

Type de données

text

Alias
UMLS CUI [1]
C0376478
Clinical interpretation
Description

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

Type de données

text

Alias
UMLS CUI [1]
C4086187
Comment
Description

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

Type de données

text

Alias
UMLS CUI [1]
C0947611
Examination not done
Description

Details to explicitly record that this examination was not performed.

Type de données

text

Alias
UMLS CUI [1,1]
C1272696
UMLS CUI [1,2]
C0031809
Structured body site
Description

A structured description of the area of skin under examination.

Type de données

text

Alias
UMLS CUI [1]
C1515974
Finding summary
Description

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

Type de données

text

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

Identification of the clinical finding, by name or category.

Type de données

text

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

The presence or absence of the specified finding.

Type de données

text

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

Narrative description about the specified finding.

Type de données

text

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

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

Type de données

integer

Alias
UMLS CUI [1]
C0243095
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Similar models

openEHR-EHR-CLUSTER.exam_skin.v0

1 Formulaires
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_skin.v0
    1. openEHR-EHR-CLUSTER.exam_skin.v0
Name
Type
Description | Question | Decode (Coded Value)
Type de données
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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