ID

29608

Beschreibung

http://openehr.org/ckm/ Use to record a narrative description, structured details and clinical interpretation about findings observed during the examination of any body fluid at a body site or from an identified body source, usually as part of a physical examination by a clinician. This archetype has been specifically designed to be used as the framework for recording details about examination of any body fluid. In order to record examination findings for: - specific types of fluids with unique attributes that need to be recorded, it is intended that a specific CLUSTER archetype for this purpose be nested within the 'Specific findings' SLOT. For example additional details only relevant to clear fluids will be recorded within a specific archetype for this purpose that will effectively extend this generic body fluid archetype; and - multicomponent body fluids such as amniotic fluid that may also contain obvious blood, meconium or pus, it is intended that one instance of this archetype be used to describe the amniotic fluid overall and additional instances of this same archetype will be nested with the 'Specific findings' SLOT to represent each of blood, meconium and pus. Body fluid is a liquid that originates from the human body, and this archetype is intended to support detailed description of: - normal physiological fluids; - physiological fluids that may be altered due to a pathological process; and - fluids generated as part of a pathological process within the body. Examples include, but are not limited to: - Amniotic fluid; - Blood and plasma; - Cerebrospinal fluid; - Discharge; - Urine; - Pus; - Saliva; - Sputum; - Synovial fluid; - Sweat; and - Vomitus. While this archetype will most likely be used in the context of a living subject, it is also appropriate to use in recording autopsy findings. Context about the body site or source will usually be carried in the archetypes in which it is nested, including but not limited to: - in the 'Examination findings' SLOT within many of the CLUSTER.exam family of archetypes and related inspection and palpation archetypes; - in the 'Physical properties' SLOT within the CLUSTER.specimen archetype; - in the 'Additional details' SLOT within the OBSERVATION.urinalysis, the OBSERVATION.fluid_output archetypes; and - within other OBSERVATION or CLUSTER archetypes, where clinically appropriate. 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.

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

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