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

ARCHETYPE ID	openEHR-EHR-CLUSTER.inspection-skin-wound.v1
Concept	Inspection of open wound
Description	The findings on inspection of a wound
Use	For use with the exam clusters for recording findings on inspection
Misuse	Should only be used in the exam observation
Purpose	For recording the findings on inspection of a wound
References
Copyright	copyright (c) 2009 openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 10/04/2007
Other Details Language	Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 10/04/2007
Other Details (Language Independent)	References:
Keywords	inspect, visual, skin, wound
Lifecycle	AuthorDraft
Language used	en
Citeable Identifier	1013.1.238
items
Normal statements	Normal statements: An optional group of statements about the normality of the inspection
Normal statement	Normal statement: A specific statement about the normality of inspection
Clinical Description	Clinical Description: Clinical description of the findings on inspection
Findings	Findings: Specific findings on inspection
Type	Type: Type of wound at0.0.71::Abrasion (graze) [] at0.0.72::Laceration [] at0.0.73::Incision [] at0.0.74::Puncture wound [] at0.0.75::Penetration wound [] at0.0.76::Gunshot wound []
Location	Location: The location of any findings
Description	Description: Description of the location of the findings
Extent	Extent: *
Starting point	Starting point: *
End point	End point: *
Course	Course: *
Colour description	Colour description: The colour of the object under inspection
Depth	Depth: *
Description	Description: *
Tissue involvement	Tissue involvement: *
Ligament	Ligament: *
Muscle	Muscle: *
Bone	Bone: *
Joint	Joint: *
Subcutaneous fat	Subcutaneous fat: *
Skin only	Skin only: *
Shape or distribution	Shape or distribution: The shape or distribution of the object inspected
Description	Description: Description of the
Symmetrical	Symmetrical: Whether the distribution is symmetrical
Age	Age: * at0.0.63::Acute [] at0.0.64::Chronic []
Signs of infection	Signs of infection: Presence of signs of infection
Cluster: Signs of infection	Cluster: Signs of infection: * Include: openEHR-EHR-CLUSTER.signs_of_infection.v1 Exclude: All not explicitly included archetypes
Size	Size: *
Cluster: Dimensions	Cluster: Dimensions: * Include: openEHR-EHR-CLUSTER.size.v1 or openEHR-EHR-CLUSTER.dimensions.v1 or openEHR-EHR-CLUSTER.dimensions-circumference.v1
Contour	Contour: The contour of the object of inspection
Wound bed	Wound bed: *
Surface	Surface: A description of the surface
Eschar present	Eschar present: *
Necrotic tissue	Necrotic tissue: * 0: at0.0.100::- [Absent] 1: at0.0.101::+ [Minimal] 2: at0.0.102::++ [Moderate] 3: at0.0.103::+++ [Excessive] Assumed value: 0: -
Slough	Slough: * 0: at0.0.96::- [Absent] 1: at0.0.97::+ [Minimal] 2: at0.0.98::++ [Moderate] 3: at0.0.99::+++ [Excessive] Assumed value: 0: -
Granulation tissue	Granulation tissue: *
Overgranulation	Overgranulation: *
Epithelialisation	Epithelialisation: *
Thickness	Thickness: Thickness of skin at0.57::Thickened [] at0.58::Normal [] at0.59::Thinned/Atrophic [*]
Surrounds	Surrounds: *
Normal/Healthy	Normal/Healthy: *
Surrounds	Surrounds: Description of immediate surrounds to object
Induration	Induration: *
Present	Present: *
Description	Description: *
Callus present	Callus present: *
Maceration present	Maceration present: *
Eczema present	Eczema present: *
Blisters	Blisters: *
Present	Present: *
Description	Description: *
Fragile skin present	Fragile skin present: *
Dry skin present	Dry skin present: *
Erythema present	Erythema present: *
Cellulitis present	Cellulitis present: *
Oedema present	Oedema present: *
Fistula or sinus present	Fistula or sinus present: *
Pigmentation	Pigmentation: Pigmentation of skin
Contamination	Contamination: Description about contamination of the wound
Odour	Odour: * at0.0.123::None [] at0.0.124::Malodourous []
Foreign body	Foreign body: *
Present	Present: *
Details	Details: *
Discharge	Discharge: *
Cluster: Fluids	Cluster: Fluids: * Include: openEHR-EHR-CLUSTER.fluid.v1 Exclude: All not explicitly included archetypes
Edge	Edge: Findings about the edge of the object under inspection
Description	Description: Description of the edge or border of the object of inspection
Definition	Definition: The nature of the edge of the object of examination at0030::Well defined [The edge is clearly defined] at0031::Moderately defined [The edge is defined but less clear in places] at0032::Poorly defined [The edge is not defined clearly in many places]
Slope	Slope: * at0.0.127::Punched out [Vertical edge] at0.0.128::Undermined [Slope inwards] at0.0.129::Everted [Slope outwards]
Translucent	Translucent: Is the object of inspection translucent?
Detail	Detail: Detailed examination of a finding on inspection
Cluster: Exam	Cluster: Exam: Exam details Include: openEHR-EHR-CLUSTER.exam.v1
Method	Method: Record of findings on inspection using a specific method at0.53::Direct visualisation [Macroscopic; By eye] at0.54::Wood's lamp [] at0.55::Dermatoscope []
Drawing	Drawing: A drawing of the findings on inspection image/cgm, image/gif, image/png, image/tiff, image/jpeg
Other contributors
Translators