ARCHETYPE Inspection of Ear Canal (openEHR-EHR-CLUSTER.inspection-ear_canal.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.inspection-ear_canal.v1
ConceptInspection of Ear Canal
DescriptionThe findings on physical examination of the ear canal by inspection!
UseFor use with the exam clusters for recording findings on inspection of the ear canal
MisuseShould only be used in the exam observation
PurposeAn archetype for recording the findings on inspection of the ear canal
References
Copyrightcopyright (c) 2009 openEHR Foundation
AuthorsAuthor name: Ian McNicoll
Organisation: Ocean Informatics
Date originally authored: 02/11/2007
Other Details LanguageAuthor name: Ian McNicoll
Organisation: Ocean Informatics
Date originally authored: 02/11/2007
Other Details (Language Independent)
  • References:
Keywordsinspect, visual, ear, canal, wax, discharge
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.233
items
Normal statementsNormal statements: An optional group of statements about the normality of the inspection
Normal statementNormal statement: A specific statement about the normality of inspection
  • Ear canal normal [*]
  • No foreign body [*]
Clinical DescriptionClinical Description: Clinical description of the findings on inspection of the ear canal
FindingsFindings: Specific findings on inspection of the ear canal
Colour descriptionColour description: The colour of the object under inspection
LocationLocation: The location of any findings
DescriptionDescription: Description of the location of the findings
Shape or distributionShape or distribution: The shape or distribution of the object inspected
DescriptionDescription: Description of the
SymmetricalSymmetrical: Whether the distribution is symmetrical
ContourContour: The contour of the object of inspection
Overlying skin or surfaceOverlying skin or surface: A description of the surface
SurroundsSurrounds: Description of immediate surrounds to object
EdgeEdge: Findings about the edge of the object under inspection
DescriptionDescription: Description of the edge or border of the object of inspection
DefinitionDefinition: The nature of the edge of the object of examination
  • Well defined [The edge is clearly defined]
  • Moderately defined [The edge is defined but less clear in places]
  • Poorly defined [The edge is not defined clearly in many places]
TranslucentTranslucent: Is the object of inspection translucent?
Foreign bodyForeign body: Details of any foreign body present
PresentPresent: Foreign body is present
Name/IdentificationName/Identification: Identify foreign body
DescriptionDescription: A description of any foreign body in the ear canal
Presence of WaxPresence of Wax: The amount of wax visible
0: No wax present [*]
1: Scant wax present [*]
2: Moderate wax present [*]
3: Profuse wax present [*]

Assumed value: 0: No wax present
DischargeDischarge: The nature of any discharge in the ear canal
Present Present : Discharge present
DetailDetail: Detailed description of the discharge
Cluster: FluidsCluster: Fluids: *
Include:
openEHR-EHR-CLUSTER.fluid.v1
Clinical DescriptionClinical Description: Clinical description of the findings on inspection of the ear canal
DetailDetail: Other detailed examination of a finding on inspection of the ear canal
Cluster: ExamCluster: Exam: Exam details
Include:
openEHR-EHR-CLUSTER.exam.v1
DrawingDrawing: A drawing of the findings on inspection
image/cgm, image/gif, image/png, image/tiff, image/jpeg
Other contributorsHeather Leslie
Translators