ARCHETYPE Inspection of blunt traumatic injury (openEHR-EHR-CLUSTER.inspection-trauma.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.inspection-trauma.v1
ConceptInspection of blunt traumatic injury
DescriptionThe findings on physical examination by inspection of blunt traumatic injury
UseFor use with the exam clusters for recording findings on inspection
MisuseShould only be used in the exam observation
PurposeA generic archetype for recording the findings on inspection of blunt traumatic injury.
References
Copyrightcopyright (c) 2009 openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 23/04/2007
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 23/04/2007
Other Details (Language Independent)
  • References:
Keywordsinspect, visual, trauma, injury
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.240
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
Clinical DescriptionClinical Description: Clinical description of the findings on inspection
FindingsFindings: Specific findings on inspection
LocationLocation: The location of any findings
DescriptionDescription: Description of the location of the findings
Colour descriptionColour description: The colour of the object under inspection
BruisingBruising: Details of bruising
DeformityDeformity: Details of deformity
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?
DetailDetail: Detailed examination of a finding on inspection
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
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