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openEHR-EHR-CLUSTER.exam_skin.v0

- 10/04/2018 - 1 Formulário, 1 Grupo de itens, 15 Elementos de dados, 2 Idiomas

Grupo de itens: openEHR-EHR-CLUSTER.exam_skin.v0.xml

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.

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