ARCHETYPE Examination of Scar (openEHR-EHR-CLUSTER.scar.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.scar.v1
ConceptExamination of Scar
DescriptionPhysical examination of a single scar in the skin resulting from repair of a wound or injury.
UseUse to record the examination findings from the physical examination of a single scar in the skin. If multiple scars are observed during examination, these should be recorded separately. Designed to be used with SLOTs within clinically appropriate OBSERVATION or other CLUSTER archetypes as part of recording the findings on clinical examination.
PurposeFor recording the examination findings from the physical examination of a single scar in the skin.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics, Australia
Email: heather.leslie@oceaninformatics.com
Date originally authored: 01-11-2012
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics, Australia
Email: heather.leslie@oceaninformatics.com
Date originally authored: 01-11-2012
OtherDetails Language Independent{current_contact=Heather Leslie, Ocean Informatics, Australia, heather.leslie@oceaninformatics.com, MD5-CAM-1.0.1=3399AD3177E073705551527F043C0171}
Keywordsscar, examination, inspection, skin, wound, healing, keloid, hypertrophic
LifecycleCommitteeDraft
Language useden
Citeable Identifier1013.1.1019
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Physical examination of a single scar in the skin resulting from repair of a wound or injury., archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], activities=[], credentials=[], state=[], capabilities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0009], code=at0009, itemType=ELEMENT, level=1, text=Anatomical Location, description=Identification of an anatomical location under examination for a scar., comment=Coding with a terminology is desirable, where possible. For example, mid-sternum, or right iliac fossa., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Presence of Scar?, description=Is a scar present in the anatomical location being examined?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical Description, description=Narrative description of the scar., comment=For example, the extent and possible cause of the scar., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=1, text=Healing, description=Description of the healing that has occurred., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal [The scar appears to have healed normally.]
  • Hypertrophic [The scar is raised above the surrounding skin.]
  • Keloid [The scar has healed with marked hypertrophy, with growth evident outside the original wound area.]
  • Atrophic [The scar is depressed below the surrounding skin.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Clinical Interpretation, description=Single word, phrase or brief summary description of the scar., comment=For example, the , uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], events=[], provider=[], content=[], target=[], contacts=[], protocol=[], other_participations=[], relationships=[], ism_transition=[], description=[], source=[], data=[], context=[], details=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0009], code=at0009, itemType=ELEMENT, level=1, text=Anatomical Location, description=Identification of an anatomical location under examination for a scar., comment=Coding with a terminology is desirable, where possible. For example, mid-sternum, or right iliac fossa., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Presence of Scar?, description=Is a scar present in the anatomical location being examined?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical Description, description=Narrative description of the scar., comment=For example, the extent and possible cause of the scar., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=1, text=Healing, description=Description of the healing that has occurred., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Normal [The scar appears to have healed normally.]
  • Hypertrophic [The scar is raised above the surrounding skin.]
  • Keloid [The scar has healed with marked hypertrophy, with growth evident outside the original wound area.]
  • Atrophic [The scar is depressed below the surrounding skin.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Clinical Interpretation, description=Single word, phrase or brief summary description of the scar., comment=For example, the , uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]