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

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-nose.v1
ConceptExamination of nose
DescriptionFor recording findings on physical examination of the nose.
UseTo recording findings on physical examination of the nose, generally within an OBSERVATION archetype.
PurposeA generic cluster for recording findings on physical examination of the nose.
References
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 02/11/2007
Other Details LanguageAuthor name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 02/11/2007
Other Details (Language Independent)
  • References:
  • MD5-CAM-1.0.1: DEC6EFA2C01EDB9C9BBDB2F812AAC7B5
Keywordsexamination, physical, nose, turbinates, smell
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.228
items
Normal statementsNormal statements: A group of statements about the normality of the examination.
Normal statementNormal statement: A specific statement of normality.
  • Nose examination normal [The nose was normal on examination.]
Clinical descriptionClinical description: Textural description of the part examined.
FindingsFindings: Clinical findings.
ExternalExternal: Findings on inspection of the external nose.
DescriptionDescription: Clinical description of external aspect of nose.
DetailDetail: More focused examination findings.
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.physical_properties.v1 and specialisations or
openEHR-EHR-CLUSTER.exam-bone.v1 and specialisations or
openEHR-EHR-CLUSTER.inspection-trauma.v1 and specialisations
NaresNares: Examination of the nares/nostrils.
Nares patent?Nares patent?: Are the nares patent?
Nasal breathing?Nasal breathing?: Is the patient breathing nasally?
DescriptionDescription: Clinical description of external aspect of nose.
InternalInternal: Internal inspection of the nose.
DescriptionDescription: Clinical description of external aspect of nose.
Nasal septumNasal septum: Inspection of the nasal septum.
DescriptionDescription: Clinical description of external aspect of nose.
Septal haematomaSeptal haematoma: Presence of septal haematoma.
Septal detailSeptal detail: Detail about nasal septa.
Include:
openEHR-EHR-CLUSTER.inspection.v1 or
openEHR-EHR-CLUSTER.inspection-trauma.v1
Nasal mucosaNasal mucosa: Findings on inspection of the nasal mucosa.
DescriptionDescription: Clinical description of external aspect of nose.
Mucosal detailMucosal detail: Detail about nasal mucosa.
Include:
openEHR-EHR-CLUSTER.inspection.v1 and specialisations
TurbinatesTurbinates: Inspection of the nasal turbinates.
DescriptionDescription: Clinical description of external aspect of nose.
Turbinate detailTurbinate detail: detail about turbinates.
Include:
openEHR-EHR-CLUSTER.inspection.v1 and specialisations
DischargeDischarge: Nasal discharge.
DescriptionDescription: Clinical description of external aspect of nose.
Discharge detailDischarge detail: Details of nasal discharge.
Include:
openEHR-EHR-CLUSTER.bodily_substance.v1 and specialisations
ImageImage: Drawing or image of the area examined.
image/gif, image/png, image/jpeg
Other contributorsHeather Leslie, Ocean Informatics, Australia
Translators