ID

29606

Description

http://openehr.org/ckm/ Use to record a narrative description, structured details and clinical interpretation about the findings observed during examination of sputum, which could occur during routine clinical observations or as part of a physical examination. This archetype has been designed to record the examination findings of sputum being observed. It is assumed that the option to record whether sputum is present/absent or if a cough is productive/unproductive will be captured in the relevant parent archetype. This archetype has been designed to be used within: - the 'Examination findings' SLOT in the OBSERVATION.exam and related CLUSTER archetypes; - the OBSERVATION.fluid_output to describe the sputum being measured; or - the OBSERVATION.laboratory_test to desctibe physical properties about a sputum sample/specimen. It can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate.

Link

http://openehr.org/ckm/

Keywords

Versions (1)
  1. 4/10/18 4/10/18 - Halim Ugurlu
Copyright Holder

openEHR Foundation

Uploaded on

April 10, 2018

DOI

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License

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

English

openEHR-EHR-CLUSTER.exam_sputum.v0

1 forms  
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_sputum.v0
    1. openEHR-EHR-CLUSTER.exam_sputum.v0
openEHR-EHR-CLUSTER.exam_sputum.v0.xml
Description

openEHR-EHR-CLUSTER.exam_sputum.v0.xml

Alias
UMLS CUI-1
C0038056
UMLS CUI-2
C0031809
Examination of sputum
Description

Findings observed during the examination of sputum.

Data type

text

Alias
UMLS CUI [1,1]
C0038056
UMLS CUI [1,2]
C0031809
Clinical description
Description

Narrative description about the sputum.

Data type

text

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

Type of sputum, categorised by the major components.

Data type

text

Alias
UMLS CUI [1]
C0038056
Colour
Description

The overall colour of the sputum.

Data type

text

Alias
UMLS CUI [1]
C0009393
Presence
Description

The identified finding visible in the sputum.

Data type

text

Alias
UMLS CUI [1,1]
C0012634
UMLS CUI [1,2]
C0150312
Consistency
Description

Viscosity of the sputum.

Data type

text

Alias
UMLS CUI [1,1]
C0042784
UMLS CUI [1,2]
C0038056
Odour
Description

Narrative description of the smell.

Data type

text

Alias
UMLS CUI [1]
C0028884
Blood presence
Description

Sputum contains visible blood.

Data type

text

Alias
UMLS CUI [1,1]
C0005767
UMLS CUI [1,2]
C0150312
Blood clot presence
Description

Sputum contains coagulated blood.

Data type

text

Alias
UMLS CUI [1,1]
C0302148
UMLS CUI [1,2]
C0150312
Blood description
Description

Narrative description of visible blood.

Data type

text

Alias
UMLS CUI [1,1]
C0005767
UMLS CUI [1,2]
C0678257
Description
Description

Narrative description about the identified finding.

Data type

text

Alias
UMLS CUI [1]
C0678257
Additional findings
Description

Additional structured details about the examination of the sputum.

Data type

text

Alias
UMLS CUI [1]
C1534840
Mulitmedia representation
Description

Digital image, video or diagram representing the examination findings.

Data type

text

Alias
UMLS CUI [1]
C0376478
Clinical interpretation
Description

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

Data type

text

Alias
UMLS CUI [1]
C4086187
Comment
Description

Additional narrative about the examination of the sputum, not captured in other fields.

Data type

text

Alias
UMLS CUI [1]
C0947611
Examination not done
Description

Details to explicitly record that this examination was not performed.

Data type

text

Alias
UMLS CUI [1,1]
C0582103
UMLS CUI [1,2]
C1272696
Age of blood
Description

Indication of the freshness of the blood present.

Data type

text

Alias
UMLS CUI [1,1]
C0005767
UMLS CUI [1,2]
C0001779
Other findings
Description

Other identified findings in the sputum.

Data type

text

Alias
UMLS CUI [1]
C1335151
Finding
Description

Identified finding in the sputum.

Data type

text

Alias
UMLS CUI [1]
C0243095
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Similar models

openEHR-EHR-CLUSTER.exam_sputum.v0

1 forms
  1. StudyEvent: openEHR-EHR-CLUSTER.exam_sputum.v0
    1. openEHR-EHR-CLUSTER.exam_sputum.v0
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
openEHR-EHR-CLUSTER.exam_sputum.v0.xml
C0038056 (UMLS CUI-1)
C0031809 (UMLS CUI-2)
Examination of sputum
Item
Examination of sputum
text
C0038056 (UMLS CUI [1,1])
C0031809 (UMLS CUI [1,2])
Clinical description
Item
Clinical description
text
C0678257 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Item
Type
text
C0038056 (UMLS CUI [1])
Type
Code List
Type
CL Item
Mucoid (1)
CL Item
Mucopurulent (2)
CL Item
Purulent (3)
Item
Colour
text
C0009393 (UMLS CUI [1])
Colour
Code List
Colour
CL Item
Clear (1)
CL Item
White (2)
CL Item
Grey (3)
CL Item
Yellow (4)
CL Item
Green (5)
CL Item
Rust (6)
CL Item
Brown (7)
CL Item
Pink (8)
CL Item
Black (9)
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)
Item
Consistency
text
C0042784 (UMLS CUI [1,1])
C0038056 (UMLS CUI [1,2])
Consistency
Code List
Consistency
CL Item
Thin (1)
CL Item
Thick (2)
Odour
Item
Odour
text
C0028884 (UMLS CUI [1])
Item
Blood presence
text
C0005767 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
Blood presence
Code List
Blood presence
CL Item
None (1)
CL Item
Blood streaked (2)
CL Item
Patchy (3)
CL Item
Uniform (4)
Item
Blood clot presence
text
C0302148 (UMLS CUI [1,1])
C0150312 (UMLS CUI [1,2])
Blood clot presence
Code List
Blood clot presence
CL Item
Present (1)
CL Item
Absent (2)
Blood description
Item
Blood description
text
C0005767 (UMLS CUI [1,1])
C0678257 (UMLS CUI [1,2])
Description
Item
Description
text
C0678257 (UMLS CUI [1])
Additional findings
Item
Additional findings
text
C1534840 (UMLS CUI [1])
Mulitmedia representation
Item
Mulitmedia 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
C0582103 (UMLS CUI [1,1])
C1272696 (UMLS CUI [1,2])
Item
Age of blood
text
C0005767 (UMLS CUI [1,1])
C0001779 (UMLS CUI [1,2])
Age of blood
Code List
Age of blood
CL Item
Fresh blood (1)
CL Item
Old blood (2)
Other findings
Item
Other findings
text
C1335151 (UMLS CUI [1])
Item
Finding
text
C0243095 (UMLS CUI [1])
Finding
Code List
Finding
CL Item
Mucus plug (1)
CL Item
Foreign body (2)
CL Item
Froth (3)
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