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Physical examination findings (EHR Archetype) - openEHR-EHR-OBSERVATION.exam.v1

- 2017-07-10 - 1 Formulär, 1 Item-grupp, 8 Dataelement, 7 Språk
Item-grupp: openEHR-EHR-OBSERVATION.exam.v1.xml
Derived from www.openehr.org . Use to record details about findings on physical examination of the subject of care. This may include a narrative description of the findings, a framework in which to nest detailed CLUSTER examination archetypes, and a clinical interpretation of the findings. Examples of detailed CLUSTER examination archetypes include those that describe inspection, palpation, auscultation, percussion and movement of body systems or anatomical structures, such as CLUSTER.exam_pupils. Narrative descriptions of clinical findings from existing clinical systems may be captured using the 'Description' data element. Clinicians may sometimes want to record a summative phrase such as 'chronic otitis media' as an Interpretation of the physical examination. In the context of the physical examination archetype this should only be understood as 'physical signs are consistent with chronic otitis media'. While the summative phrase may appear to represent a diagnosis, safe and consistent querying requires a diagnosis to be recorded using the EVALUATION.problem_diagnosis archetype, even if the phrases are identical.

Exclusion of examination (EHR archetype) - openEHR-EHR-CLUSTER.exclusion_exam.v1

- 2017-07-08 - 1 Formulär, 1 Item-grupp, 3 Dataelement, 1 Språk
Item-grupp: openEHR-EHR-CLUSTER.exclusion_exam.v1.xml
Derived from www.openehr.org Use to record in a clinical examination that the physical examination, or a specified part of the physical examination, was not performed, with an optional statement about the reason for the non-performance. This archetype has been designed to be used to allow recording of 'no examination was done' at multiple levels of the examination process. It will never be used as a stand-alone archetype but always inside an examination archetype that provides the context for the examination being performed. For example, insertion of this archetype into the Examination Detail' SLOT within OBSERVATION.exam allows for recording that no physical examination was performed. Similarly, insertion of this archetype into the Details SLOT of any examination-related CLUSTER archetype, such as CLUSTER.exam_eye_pupil, allows recording that no physical examination was performed only for examination of a specified pupil, perhaps because a facial injury prevented the pupil being visualised. In particular, this archetype has specifically been designed to avoid the need to use flags or terminology to express negation about a record of physical examination within the health record. It is reasonable to assume that if the examination was partially performed, then only data about the examination performed will be recorded. If the examination was difficult to perform, for example an uncooperative patient, then this information can be included in the overall 'Confounding Factors' data element in the root OBSERVATION.exam archetype or in the 'Comment' data element in each examination CLUSTER archetype.

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