ARCHETYPE Examination of Ears (openEHR-EHR-CLUSTER.exam_ears.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_ears.v1
ConceptExamination of Ears
DescriptionFindings observed during the physical examination of the ears.
UseUse to record a narrative description of the overall findings observed during the physical examination of the ears. Use as a container archetype - to provide a framework in which specific, detailed CLUSTER archetypes related to ear examination findings can be nested. For example, CLUSTER.exam_tympanic_membrane, CLUSTER.exam_auditory_canal and CLUSTER.exam.pinna can be inserted into relevant slots to record detailed physical examination findings for a specific ear. In addition the CLUSTER.exclusion_exam can be used to record that an ear examination was not done, if inserted at root level 'Other Details' SLOT, or that examination of a specified ear was not done, if inserted in the 'Details' SLOT of the relevant ear. 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.
MisuseNot to be used for recording data not related to the physical examination of the ears. Not to be used to record data about ear testing - use specific purpose-built OBSERVATION archetypes. For example: OBSERVATION.audiometry_result or OBSERVATION.tympanogram_226hz. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure, OBSERVATION.body_weight, or OBSERVATION.height.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the physical examination of the ears, and to provide a framework in which to nest detailed CLUSTER archetypes, each of which can further describe specific aspects of the ear examination in more detail.
References
Copyright© National E-Health Transition Authority, openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-02-05
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2013-02-05
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Ocean Informatics, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=9025CA00AE92843DBC3EC8FC13859769, build_uid=df2c5b7a-32fd-4a02-bc12-840f81e1b4aa, revision=1.0.0}
Keywordsexamination, physical, clinical, findings, ear, exam
Lifecyclepublished
UIDad677864-e49a-40c2-b211-52fd1876beb6
Language useden
Citeable Identifier1013.1.1462
Revision Number1.0.0
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  • Left ear [*]
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openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1 and specialisations Or
openEHR-EHR-CLUSTER.exam_pinna.v1 and specialisations Or
openEHR-EHR-CLUSTER.exam_auditory_canal.v1 and specialisations Or
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=SLOT, level=1, text=Other details, description=Structured details about the physical examination of the ears not captured elsewhere in this archetype., comment=For example: information required to capture local context; information required to align with other reference models/formalisms; or recording that the examination was not performed., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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  • Left ear [*]
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openEHR-EHR-CLUSTER.exam_pinna.v1 and specialisations Or
openEHR-EHR-CLUSTER.exam_auditory_canal.v1 and specialisations Or
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