| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_skin.v0 |
|---|---|
| Concept | Examination of skin |
| Description | Findings observed during the physical examination of an area of skin. |
| Use | 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. |
| Misuse | Not to be used for recording data not related to the physical examination of skin. 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 or test results - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure or OBSERVATION.imaging_exam. |
| Purpose | For recording a description and clinical interpretation of the findings observed during the physical examination of an identified area of skin. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Silje Ljosland Bakke Organisation: Nasjonal IKT HF, Norway Date originally authored: 2015-06-08 |
| Other Details Language | Author name: Silje Ljosland Bakke Organisation: Nasjonal IKT HF, Norway Date originally authored: 2015-06-08 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | in_development |
| UID | 90f5e49f-48be-4d04-ba90-257d24bcbcb1 |
| Language used | en |
| Citeable Identifier | 1013.1.1793 |
| Revision Number | 0.0.1-alpha |
| items | |
| Body site | Body site: Identification of the area of skin under examination. For example, entire body, face or right cheek. If the body site has previously been identified in another archetype in which this archetype is nested, this data element becomes redundant. |
| Structured body site | Structured body site: A structured description of the area of skin under examination. If the body site has previously been identified in another archetype in which this archetype is then nested, this SLOT becomes redundant. Include: openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ |
| No abnormality detected | No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination. Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal skin examination'. Allowed values: {true} |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the skin examination. |
| Finding summary | Finding summary: Summary information about findings on the skin at the identified body site. Use this cluster of data elements where it makes sense to record summary information only. For example: the presence/absence of the identified finding (such as psoriasis), or the number of items (such as number of condyloma present). |
| Finding | Finding: Identification of the clinical finding, by name or category. 'Finding' should be coded with a terminology, where possible. |
| Presence | Presence: The presence or absence of the specified finding.
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| Clinical description | Clinical description: Narrative description about the specified finding. |
| Number | Number: The number of the specified finding observed in the identified body site. For example, papilloma or rash. |
| Examination findings | Examination findings: Structured details about one or more specific findings on physical examination of the identified skin site. For example, allowing fractal examination of a more specific area of the skin site. It could also be used to record the examination of a specific lesion or wound, for example by using the 'Alias' data element in CLUSTER.exam_burn or CLUSTER.exam_lesion. Include: openEHR-EHR-CLUSTER.exam_ openEHR-EHR-CLUSTER.exam_ openEHR-EHR-CLUSTER.exam_ |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Include: openEHR-EHR-CLUSTER.multimedia.v1 and specialisations |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør) Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør) Heather Leslie, Ocean Informatics, Australia (openEHR Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) |
| Translators |