ARCHETYPE Inspection of skin (openEHR-EHR-CLUSTER.inspection-skin.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.inspection-skin.v1
ConceptInspection of skin
DescriptionThe findings on inspection of the skin
UseFor use with the exam clusters for recording findings on inspection
MisuseShould only be used in the exam observation
PurposeFor recording the findings on inspection of the skin
References
Copyrightcopyright (c) 2009 openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 10/04/2007
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 10/04/2007
OtherDetails Language Independent{references=}
Keywordsinspect, visual, skin
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.236
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The findings on inspection of the skin, archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], activities=[], credentials=[], state=[], capabilities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=CLUSTER, level=1, text=Normal statements, description=An optional group of statements about the normality of the inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Normal statement, description=A specific statement about the normality of inspection, comment=null, 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[at0048], code=at0048, itemType=ELEMENT, level=1, text=Clinical Description, description=Clinical description of the findings on inspection, 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[at0006], code=at0006, itemType=CLUSTER, level=1, text=Findings, description=Specific findings on inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0.52], code=at0.52, itemType=ELEMENT, level=2, text=Method, description=Record of findings on inspection using a specific method, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Direct visualisation [Macroscopic; By eye]
  • Wood's lamp [*]
  • Dermatoscope [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0036], code=at0036, itemType=ELEMENT, level=2, text=Colour description, description=The colour of the object under inspection, 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[at0006]/items[at0005], code=at0005, itemType=CLUSTER, level=2, text=Location, description=The location of any findings, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0005]/items[at0022], code=at0022, itemType=ELEMENT, level=3, text=Description, description=Description of the location of the findings, comment=null, 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[at0006]/items[at0018], code=at0018, itemType=CLUSTER, level=2, text=Shape or distribution, description=The shape or distribution of the object inspected, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=Description, description=Description of the , 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[at0006]/items[at0018]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Symmetrical, description=Whether the distribution is symmetrical, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0051], code=at0051, itemType=ELEMENT, level=2, text=Contour, description=The contour of the object of inspection, 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[at0006]/items[at0027], code=at0027, itemType=ELEMENT, level=2, text=Surface, description=A description of the surface, 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[at0006]/items[at0.56], code=at0.56, itemType=ELEMENT, level=2, text=Thickness, description=Thickness of skin, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thickened [*]
  • Normal [*]
  • Thinned/Atrophic [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Surrounds, description=Description of immediate surrounds to object, 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[at0006]/items[at0.60], code=at0.60, itemType=ELEMENT, level=2, text=Pigmentation, description=Pigmentation of skin, 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[at0006]/items[at0028], code=at0028, itemType=CLUSTER, level=2, text=Edge, description=Findings about the edge of the object under inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0028]/items[at0033], code=at0033, itemType=ELEMENT, level=3, text=Description, description=Description of the edge or border of the object of inspection, 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[at0006]/items[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=3, text=Definition, description=The nature of the edge of the object of examination, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0034], code=at0034, itemType=ELEMENT, level=2, text=Translucent, description=Is the object of inspection translucent?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0049], code=at0049, itemType=CLUSTER, level=2, text=Detail, description=Detailed examination of a finding on inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0049]/items[at0052], code=at0052, itemType=SLOT, level=3, text=Exam details, description=Exam details, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0050], code=at0050, itemType=ELEMENT, level=1, text=Drawing, description=A drawing of the findings on inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null]], events=[], provider=[], content=[], target=[], contacts=[], protocol=[], other_participations=[], relationships=[], ism_transition=[], description=[], source=[], data=[], context=[], details=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000.1, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=CLUSTER, level=1, text=Normal statements, description=An optional group of statements about the normality of the inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Normal statement, description=A specific statement about the normality of inspection, comment=null, 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[at0048], code=at0048, itemType=ELEMENT, level=1, text=Clinical Description, description=Clinical description of the findings on inspection, 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[at0006], code=at0006, itemType=CLUSTER, level=1, text=Findings, description=Specific findings on inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0.52], code=at0.52, itemType=ELEMENT, level=2, text=Method, description=Record of findings on inspection using a specific method, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Direct visualisation [Macroscopic; By eye]
  • Wood's lamp [*]
  • Dermatoscope [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0036], code=at0036, itemType=ELEMENT, level=2, text=Colour description, description=The colour of the object under inspection, 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[at0006]/items[at0005], code=at0005, itemType=CLUSTER, level=2, text=Location, description=The location of any findings, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0005]/items[at0022], code=at0022, itemType=ELEMENT, level=3, text=Description, description=Description of the location of the findings, comment=null, 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[at0006]/items[at0018], code=at0018, itemType=CLUSTER, level=2, text=Shape or distribution, description=The shape or distribution of the object inspected, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0018]/items[at0019], code=at0019, itemType=ELEMENT, level=3, text=Description, description=Description of the , 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[at0006]/items[at0018]/items[at0020], code=at0020, itemType=ELEMENT, level=3, text=Symmetrical, description=Whether the distribution is symmetrical, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0051], code=at0051, itemType=ELEMENT, level=2, text=Contour, description=The contour of the object of inspection, 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[at0006]/items[at0027], code=at0027, itemType=ELEMENT, level=2, text=Surface, description=A description of the surface, 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[at0006]/items[at0.56], code=at0.56, itemType=ELEMENT, level=2, text=Thickness, description=Thickness of skin, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thickened [*]
  • Normal [*]
  • Thinned/Atrophic [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Surrounds, description=Description of immediate surrounds to object, 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[at0006]/items[at0.60], code=at0.60, itemType=ELEMENT, level=2, text=Pigmentation, description=Pigmentation of skin, 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[at0006]/items[at0028], code=at0028, itemType=CLUSTER, level=2, text=Edge, description=Findings about the edge of the object under inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0028]/items[at0033], code=at0033, itemType=ELEMENT, level=3, text=Description, description=Description of the edge or border of the object of inspection, 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[at0006]/items[at0028]/items[at0029], code=at0029, itemType=ELEMENT, level=3, text=Definition, description=The nature of the edge of the object of examination, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 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]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0034], code=at0034, itemType=ELEMENT, level=2, text=Translucent, description=Is the object of inspection translucent?, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0049], code=at0049, itemType=CLUSTER, level=2, text=Detail, description=Detailed examination of a finding on inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006]/items[at0049]/items[at0052], code=at0052, itemType=SLOT, level=3, text=Exam details, description=Exam details, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0050], code=at0050, itemType=ELEMENT, level=1, text=Drawing, description=A drawing of the findings on inspection, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/cgm, image/gif, image/png, image/tiff, image/jpeg, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]