| ARCHETYPE ID | openEHR-EHR-CLUSTER.palpation.v1 |
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| Concept | Palpation |
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| Description | Findings on palpation. |
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| Use | To be embedded in the openEHR-EHR-OBSERVATION.exam cluster to express findings determined by palpation. |
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| Misuse | Not for use in any other context at present. |
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| Purpose | To record data found on examination through palpation. |
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| References | |
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| Copyright | copyright (c) 2010 openEHR Foundation |
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| Authors | Author name: unknown
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| Other Details Language | Author name: unknown
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| Other Details (Language Independent) | - References:
- MD5-CAM-1.0.1: 6997D54D3789258C693D939FAFFB0CEE
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| Keywords | palpate |
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| Lifecycle | AuthorDraft |
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| Language used | en |
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| Citeable Identifier | 1013.1.12 |
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| items | |
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| Normal statements | Normal statements: A group of statements about the normality of the palpation. |
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| Normal statement | Normal statement: A specific statement of normality.
- at0013::Normal [The palpation is normal.]
- at0014::Probably normal [The palpation is apparently normal but some uncertainty exists.]
- at0015::No abnormality detected [No abnormality was detected by palpation.]
- at0060::Soft [The palpation revealed no distension, masses or rigidity.]
- at0061::No tenderness [Palpation revealed no tenderness.]
- at0068::No masses [No masses palpable.]
- at0069::No foreign bodies [No foreign bodies are palpable.]
- at0082::No hernias [Palpation revealed no hernias.]
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| Clinical description | Clinical description: Textural statement of the findings on palpation. |
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| Findings | Findings: Group of findings. |
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| Tenderness | Tenderness: A group of statements about a tenderness finding. |
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| Depth of palpation | Depth of palpation: The depth of palpation.
- at0003::Superficial [Superficial palpation of the skin and superficial muscles.]
- at0004::Deep [Palpation of the deep structures beneath superficial muscles.]
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| Degree | Degree: The amount or degree of tenderness found on palpation.
- at0006::absent [No tenderness on palpation.]
- at0021::mild [There is some feeling of pain or discomfort on palpation.]
- at0022::moderate [There is definite pain on palpation.]
- at0023::marked [Gentle palpation leads to moderate pain.]
- at0024::extreme [Gentle palpation leads to severe pain.]
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| Category | Category: The type of tenderness found on palpation.
- at0007::Superficial tenderness [Tender in the superficial layers.]
- at0008::Deep tenderness [Tenderness in the deep structures.]
- at0009::Rebound tenderness [Tenderness on releasing palpation pressure.]
- at0019::Tenderness [A group of statements about a tenderness finding.]
- at0025::Rigidity [The abdomen is rigid to palpation.]
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| Body site | Body site: The region, site or organ that is the object of localised palpation. |
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| Temperature | Temperature: The temperature on palpation.
- at0042::Cold [The feeling of cold.]
- at0043::Cool [The temperature feels cooler than normal.]
- at0044::Normal [The temperature feels normal.]
- at0045::Warm [The temperature feels warmer than normal.]
- at0046::Hot [The temperature feels hot.]
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| Guarding | Guarding: Tensing of underlying muscles on palpation. |
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| Degree | Degree: The degree of guarding.
- at0076::Not present [Guarding is not present.]
- at0077::Mild [There is some guarding with deep palpation.]
- at0078::Moderate [There is guarding on moderate palpation.]
- at0079::Gross [There is guarding on very gentle palpation.]
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| Nature | Nature: The nature of the guarding.
- at0073::Voluntary [The guarding is apparently deliberate on the part of the person.]
- at0074::Involuntary [The guarding is occuring without intent from the person.]
- at0075::Uncertain [The guarding is not clearly involuntary or voluntary.]
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| Localised palpation | Localised palpation: Palpation of a localised area. |
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| Body site | Body site: The region, site or organ that is the object of localised palpation. |
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| Cluster: Localised palpation | Cluster: Localised palpation: Palpation
Include:
openEHR-EHR-CLUSTER.palpation.v1 |
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| Cough impulse | Cough impulse: Presence of a cough impulse felt on palpation.
Allowed values: {true} |
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| (Surface/Border) | (Surface/Border): Findings related to the surface or border of the object of palpation.
Runtime name constraint:
- at0064::Surface [The surface of the object of palpation.]
- at0065::Edge [The border of the object of palpation.]
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| Site description | Site description: Details of the location of the surface or border palpated. |
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| Consistency | Consistency: The consistency of the surface or border of the object of palpation.
- at0049::Hard/Rigid [The surface is hard or rigid.]
- at0050::Firm [The surface is firm.]
- at0052::Soft [The surface is soft.]
- at0062::Boggy [The surface is soft with a boggy quality.]
- at0063::Indents [The border or surface retains indentation after firm pressure is applied.]
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| Features | Features: Features of the surface or border.
- at0055::Smooth [The surface or border is smooth.]
- at0056::Craggy [Large irregularities.]
- at0057::Irregular [The surface or border is irregular.]
- at0058::Nodular [The surface contains nodules.]
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| Detail | Detail: Detailed examination of things found on palpation. |
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| Cluster: Exam details | Cluster: Exam details: Exam details
Include:
openEHR-EHR-CLUSTER.exam.v1 or
openEHR-EHR-CLUSTER.exam-mass.v1
Exclude:
All not explicitly included archetypes |
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| Other contributors | |
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| Translators | |
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