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

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-mouth.v1
ConceptExamination of mouth
DescriptionRecord of clinical findings on physical examination of mouth.
UseUse in conjunction with separate archetype/s for dental examinations when developed.
PurposeRecording of clinical findings on physical examination of the mouth.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 23/05/2007
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 23/05/2007
Other Details (Language Independent)
  • References:
  • MD5-CAM-1.0.1: 639DFF0410427A8C48E1FDF83F6C7071
Keywordsexamination, physical, mouth, tongue, lips, tonsils
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.227
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 about the mouth.
LipsLips: Findings about lips.
DescriptionDescription: Text description of clinical findings.
Lips detailLips detail: Detail related to lips.
Include:
openEHR-EHR-CLUSTER.inspection.v1
Angle of mouthAngle of mouth: Findings about the angle of the mouth.
DescriptionDescription: Text description of clinical findings.
Angle of mouth detailAngle of mouth detail: Detail about the angle of mouth.
Include:
openEHR-EHR-CLUSTER.inspection.v1
Hard palateHard palate: Findings about the hard palate.
DescriptionDescription: Text description of clinical findings.
Soft palateSoft palate: Findings about the soft palate.
Flexible and mobileFlexible and mobile: The soft palate is flexible and mobile.
Gag responseGag response: Estimate of the gag response.
0: Absent [Absent.]
1: + [Reduced.]
2: ++ [Normal.]
3: +++ [Increased]

Assumed value: 0: Absent
Description of swallowingDescription of swallowing: Text description of swallowing.
DescriptionDescription: Text description of clinical findings.
UvulaUvula: Findings about the uvula.
DeviationDeviation: Findings of uvular deviation.
  • None [The uvula is not deviated.]
  • Deviation to right [The uvuula is deviated to the right.]
  • Deviation to left [The uvula is deviated to the left.]
DescriptionDescription: Text description of clinical findings.
Tonsillar fossaTonsillar fossa: Findings about the tonsillar fossa.
Tonsils PresentTonsils Present: The tonsils are present.
Relative SizeRelative Size: Relative size of tonsils in comparison to expected size.
0: Absent [The tonsils are absent.]
1: Reduced in size [The tonsils are reduced in size.]
2: Expected size [The tonsils are of expected size.]
3: Enlarged [The tonsils are enlarged.]
4: Grossly enlarged [The tonsils are grossly enlarged.]
DescriptionDescription: Text description of clinical findings.
PharynxPharynx: Findings about the pharynx.
DescriptionDescription: Text description of clinical findings.
TongueTongue: Findings about the tongue.
Tongue detailTongue detail: Detailed findings about the tongue.
Include:
openEHR-EHR-CLUSTER.cranial_nerves.v1 or
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations
DescriptionDescription: Text description of clinical findings.
DetailDetail: More focused examination findings.
Include:
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection.v1 and specialisations
ImageImage: Drawing or image of the area examined.
image/gif, image/png, image/jpeg
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