ARCHETYPE Skin (openEHR-EHR-CLUSTER.skin.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.skin.v1
ConceptSkin
DescriptionPhysical examination of an explicitly identified area of skin.
UseUse to record the examination findings from the physical examination of an explicitly identified area of skin. This archetype is designed to be used in SLOTs within clinically appropriate OBSERVATION or other CLUSTER archetypes as part of recording the findings on clinical examination - for example nested within OBSERVATION.exam or CLUSTER.pinna_mastoid. Inspection of the skin is assumed to be done using direct visualisation. If a device is used, it should be recorded as part of the method of examination in the ENTRY archetype - for example, the OBSERVATION.exam family of archetypes.
PurposeFor recording the examination findings from the physical examination of an explicitly identified area of skin.
ReferencesDirect communications with clinical domain experts.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2012-11-01
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2012-11-01
OtherDetails Language Independent{references=Direct communications with clinical domain experts., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, MD5-CAM-1.0.1=B01EE71FA3E00BFDA06A04F994729EA9}
Keywords
LifecycleCommitteeDraft
Language useden
Citeable Identifier1013.1.1107
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Physical examination of an explicitly identified area of skin., archetypeConceptComment=null, otherContributors=Kerrie Lee, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], activities=[], credentials=[], state=[], capabilities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Anatomical Location, description=Identification of the anatomical location of the skin being examined., comment=Coding with a terminology is desirable, where possible. For example, a broad region such as the left arm; or a smaller, specific area such as the right eyelid. If this archetype is already nested within an archetype where the appropriate level of detail for identification of the anatomical location has already been specified, this data element may be regarded as redundant, or the system may automatically insert the same anatomical location here., 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical Description, description=Narrative description of the skin of the skin., comment=For example, thickness/atrophy, or presence of pigmentation., 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=Erythema, description=Narrative description of any observed erythema or redness in the skin., comment=null, 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[at0005], code=at0005, itemType=ELEMENT, level=1, text=Swelling, description=Narrative description of any observed swelling in the skin., comment=null, 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description of any tenderness noted on palpation of the skin., comment=null, 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[at0006], code=at0006, itemType=SLOT, level=1, text=Details, description=Detailed structured examination findings., comment=For example, further details about a scar or an identified lesion, or an intravenous catheter that is inserted in the area., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.scar.v1 and specialisations Or
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Clinical Interpretation, description=Single word, phrase or brief description representing a summary of the findings of the region of skin being examined., comment=For example, infected IV site or eczema., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0009], code=at0009, itemType=ELEMENT, level=1, text=Multimedia Representation, description=Digital image, video or diagram of the skin., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=video/BT656, video/CelB, video/H261, video/H263, video/H263-1998, video/H263-2000, video/quicktime, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative comment about the examination, not captured in other structured data fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, 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[at0003], code=at0003, itemType=ELEMENT, level=1, text=Anatomical Location, description=Identification of the anatomical location of the skin being examined., comment=Coding with a terminology is desirable, where possible. For example, a broad region such as the left arm; or a smaller, specific area such as the right eyelid. If this archetype is already nested within an archetype where the appropriate level of detail for identification of the anatomical location has already been specified, this data element may be regarded as redundant, or the system may automatically insert the same anatomical location here., 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical Description, description=Narrative description of the skin of the skin., comment=For example, thickness/atrophy, or presence of pigmentation., 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=Erythema, description=Narrative description of any observed erythema or redness in the skin., comment=null, 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[at0005], code=at0005, itemType=ELEMENT, level=1, text=Swelling, description=Narrative description of any observed swelling in the skin., comment=null, 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description of any tenderness noted on palpation of the skin., comment=null, 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[at0006], code=at0006, itemType=SLOT, level=1, text=Details, description=Detailed structured examination findings., comment=For example, further details about a scar or an identified lesion, or an intravenous catheter that is inserted in the area., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.scar.v1 and specialisations Or
openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Clinical Interpretation, description=Single word, phrase or brief description representing a summary of the findings of the region of skin being examined., comment=For example, infected IV site or eczema., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0009], code=at0009, itemType=ELEMENT, level=1, text=Multimedia Representation, description=Digital image, video or diagram of the skin., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=video/BT656, video/CelB, video/H261, video/H263, video/H263-1998, video/H263-2000, video/quicktime, image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative comment about the examination, not captured in other structured data fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]