ARCHETYPE Examination of pinna & peri-auricular region (openEHR-EHR-CLUSTER.exam_pinna.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_pinna.v0
ConceptExamination of pinna & peri-auricular region
DescriptionFindings observed during the physical examination of the external structure of the ears and in the adjacent mastoid/peri-auricular region.
UseUse to record findings observed during the physical examination of a specified pinna and associated scars. 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. Specifically designed to be used within the CLUSTER.exam_ears archetype, but may be used within any clinically appropriate ENTRY or CLUSTER archetype related to physical examination of the ear.
MisuseNot 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, structured details and clinical interpretation of the findings observed during the physical examination of an identified pinnae and presence of scars in the adjacent peri-auricular region.
ReferencesExamination - Pinnae, draft archetype, National eHealth Transition Authority [Internet]. NEHTA Clinical Knowledge Manager. Authored: 09 Oct 2012. Available at: http://dcm.nehta.org.auhttp://dcm.nehta.org.au/ckm/OKM.html#showarchetype_1013.1.1095 (accessed 05 Feb 2013).

Communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program.

Northern Territory Government, Department of Health: Hearing Health Program ENT Specialist Consultation Form 2011 12 07.

Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Teleotology Nurse Consultation Form 2011 12 07.

Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Audiologist Consultation Form 2011 12 07.

OATSIH: The Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (2010). Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25792800821BE8?OpenDocument.
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, references=Examination - Pinnae, draft archetype, National eHealth Transition Authority [Internet]. NEHTA Clinical Knowledge Manager. Authored: 09 Oct 2012. Available at: http://dcm.nehta.org.auhttp://dcm.nehta.org.au/ckm/OKM.html#showarchetype_1013.1.1095 (accessed 05 Feb 2013). Communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program. Northern Territory Government, Department of Health: Hearing Health Program ENT Specialist Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Teleotology Nurse Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Audiologist Consultation Form 2011 12 07. OATSIH: The Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (2010). Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25792800821BE8?OpenDocument., 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=6CE91A2FCCE89190BC8B65FF84A05BFB, build_uid=f5920e28-995e-43ef-a6f8-2e90cb59cb8a, revision=0.0.1-alpha}
Keywordsexamination, physical, clinical, findings, exam, pinna, ear, external, auricle
Lifecyclein_development
UID05b96df3-8eec-48f6-9029-89c5fe9e6b9c
Language useden
Citeable Identifier1013.1.1845
Revision Number0.0.1-alpha
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Harvey Coates, UWA, Australia
Marissa Cookson, Dept of Health, Australia
Kimberley Crebbin, NT Hearing Services, Australia
Kathy Currie, Northern Territory Health, Australia
Jade Frederiksen, Hearing Health Program, DoH, Australia
Sam Heard, Ocean Informatics, Australia
Paul Hickey, Hearing Health Program, Australia
Oliver Hosking, Remote Health NT, Australia
Anthony Leech, Hearing Health, Australia
Kerrie Lee, Ngaanyatjarra Health Service, Australia (Editor)
Heather Leslie, Ocean Informatics, Australia (Editor)
Ian McNicoll, Ocean Informatics UK, United Kingdom
Mark Ramjan, NT Department of Health, Australia
Kelly Simmons, Department of Health, Australia
Fiona Wake, RAHC, Australia
Christine Wigger, Menzies School of Health Research, Australia, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={events=[], context=[], capabilities=[], activities=[], protocol=[], identities=[], source=[], credentials=[], state=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0010], code=at0010, itemType=ELEMENT, level=1, text=Side examined, description=Identification of the pinna examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left side [Findings for the left pinna and mastoid region.]
  • Right side [Findings for the right pinna and mastoid region.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected on examination., comment=Record as True if no abnormality was detected on examination., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position., comment=May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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[at0015], code=at0015, itemType=CLUSTER, level=1, text=Surgical scar, description=Findings about surgical scars identified on, or related to the identified pinna or mastoid region., comment=The key intent of these data element is to identify the possible existence of significant middle ear surgery where this has not been previously recorded in the subject. This is a not uncommon occurrence in the remote communities managed by NT Hearing Health., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015]/items[at0019], code=at0019, itemType=ELEMENT, level=2, text=Present?, description=Is a surgical scar present in the periaural region?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A post-surgical scar is present.]
  • Absent [A post-surgical scar is not present.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015]/items[at0016], code=at0016, itemType=ELEMENT, level=2, text=Site of scar, description=Identification of the the specific anatomical structure of the pinna or related anatomical region examined., comment=Coding of the System/Stucture with a terminology is desirable, where possible., 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[at0015]/items[at0017], code=at0017, itemType=ELEMENT, level=2, text=Scar description, description=Narrative description of the scar, including likely aetiology and state of healing., 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[at0002], code=at0002, itemType=SLOT, level=1, text=Details, description=Structured details of physical examination findings for the specific parts of the identified pinna or related structures., comment=For examination, associated lymph nodes or skin., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=ELEMENT, level=1, text=Multimedia representation, description=Digital image or video taken, or a diagram drawn, during the physical examination of the body system or anatomical structure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/cgm, image/gif, image/png, image/tiff, image/jpeg, video/BT656, video/CelB, video/H261, video/H263, video/H263-1998, video/H263-2000, video/quicktime, application/pdf, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings., comment=Coding with a terminology is preferred, if possible. For example, normal examination or a specific physical finding., 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[at0022], code=at0022, itemType=SLOT, level=1, text=Exam not done, description=Details to explicitly record that this examination was not performed., comment=null, 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 side [Findings for the left pinna and mastoid region.]
  • Right side [Findings for the right pinna and mastoid region.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected on examination., comment=Record as True if no abnormality was detected on examination., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the findings observed during a physical examination of a single identified pinna, including size, shape and position., comment=May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format., 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[at0015], code=at0015, itemType=CLUSTER, level=1, text=Surgical scar, description=Findings about surgical scars identified on, or related to the identified pinna or mastoid region., comment=The key intent of these data element is to identify the possible existence of significant middle ear surgery where this has not been previously recorded in the subject. This is a not uncommon occurrence in the remote communities managed by NT Hearing Health., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015]/items[at0019], code=at0019, itemType=ELEMENT, level=2, text=Present?, description=Is a surgical scar present in the periaural region?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A post-surgical scar is present.]
  • Absent [A post-surgical scar is not present.]
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