ARCHETYPE Examination of the abdomen (openEHR-EHR-CLUSTER.exam-abdomen.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-abdomen.v1
ConceptExamination of the abdomen
DescriptionFor recording findings on physical examination of the abdomen.
PurposeA cluster for recording findings on physical examination of the abdomen.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 11/04/2007
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 11/04/2007
Other Details (Language Independent)
  • References:
  • MD5-CAM-1.0.1: 75E4E6DE863A430A1F1C7ABF3C8DDB9A
Keywordsexamination, physical
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.219
items
Normal statementsNormal statements: A group of statements about the normality of the examination.
Normal statementNormal statement: A specific statement of normality.
Clinical descriptionClinical description: Textural description of the part examined.
FindingsFindings: Clinical findings.
Abdominal wallAbdominal wall: Findings related to the abdominal wall.
DescriptionDescription: Clinical description of findings related to the abdominal wall.
Abdominal wall detailAbdominal wall detail: Details of abdominal wall findings.
Include:
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations
Abdominal regionAbdominal region: Findings related to a specific abdominal region.
RegionRegion: The abdominal region being described.
  • Left upper quadrant [*]
  • Epigastrium [*]
  • Left upper quadrant [*]
  • Right loin [*]
  • Central/peri-umbilical [*]
  • Left loin [*]
  • Right iliac fossa [*]
  • Left iliac fossa [*]
DescriptionDescription: Clinical description of findings related to the abdominal wall.
Abdominal region detailAbdominal region detail: Detailed findings of a specific abdominal region.
Include:
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.auscultation.v1 and specialisations
Abdominal contentsAbdominal contents: Findings related to abdominal contents.
DescriptionDescription: Clinical description of findings related to the abdominal wall.
OrgansOrgans: *
LiverLiver: Findings related to liver.
DescriptionDescription: Clinical description of findings related to the abdominal wall.
Liver detailLiver detail: Detailed liver findings.
Include:
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations
SpleenSpleen: Findings related to spleen.
DescriptionDescription: Clinical description of findings related to the abdominal wall.
Spleen detailSpleen detail: Detailed spleen findings.
Include:
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations
KidneyKidney: Findings related to kidney.
DescriptionDescription: Clinical description of findings related to the abdominal wall.
Kidney detailKidney detail: Detailed kidney findings.
Include:
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations
BowelBowel: Findings related to bowel.
DescriptionDescription: Clinical description of findings related to the abdominal wall.
Bowel detailBowel detail: Detailed bowel findings.
Include:
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.auscultation.v1 and specialisations
Abdominal contents detailAbdominal contents detail: Detailed findings of abdominal contents.
Include:
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.auscultation.v1 and specialisations
DetailDetail: More focused examination findings.
Include:
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.auscultation.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations or
openEHR-EHR-CLUSTER.percussion.v1 and specialisations or
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations
ImageImage: Drawing or image of the area examined.
image/gif, image/png, image/jpeg
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