| ARCHETYPE ID | openEHR-EHR-OBSERVATION.global.v1 |
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| Concept | Global assessment |
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| Description | General assessment of the whole patient by the clinician. |
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| Use | Use in conjunction with Conscious state OBSERVATION. |
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| Purpose | To document an overall impression of the patient as part of examination. |
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| References | |
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| Copyright | copyright (c) 2010 openEHR Foundation |
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| Authors | Author name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 19/03/2007
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| Other Details Language | Author name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 19/03/2007
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| Other Details (Language Independent) | - References:
- MD5-CAM-1.0.1: 7561ACC34EF2B8E37C10B7CEBF1B85F7
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| Keywords | Global, General assessment, complexion, appearance, behaviour, hydration, mood |
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| Lifecycle | AuthorDraft |
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| Language used | en |
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| Citeable Identifier | 1013.1.249 |
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| events | |
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| Any event | Any event: @ internal @ |
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| data | |
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| Normal statements | Normal statements: General statements about normal appearance and behaviour. |
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| Clinical description | Clinical description: General description of the global impression of the patient. |
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| Skin complexion | Skin complexion: Findings related to overall skin appearance. |
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| Complexion | Complexion: Finding of skin complexion.
Choice of:
 Coded Text
- at0111::Pale [Subject appears pale.]
- at0118::Flushed [Subject appears flushed.]
- at0119::Jaundiced [Subject appears jaundiced.]
- at0120::Clammy [Subject's skin feels clammy.]
- at0121::Sweaty [Subject appears sweaty.]
- at0122::Centrally cyanosed [Subject appears centrally cyanosed.]
- at0123::Peripherally cyanosed [Subject appears peripherally cyanosed.]
- at0124::Mottled [Subject's skin appears mottled.]
 Text
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| Sweating and hydration | Sweating and hydration: Findings related to sweating and hydration. |
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| Sweat | Sweat: Detailed findings related to sweat.
Include:
openEHR-EHR-CLUSTER.fluid.v1 and specialisations
Exclude:
All not explicitly included archetypes |
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| Hydration | Hydration: Details of skin hydration.
Include:
openEHR-EHR-CLUSTER.hydration.v1 and specialisations |
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| Appearance | Appearance: Findings of general appearance. |
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| Nutrition | Nutrition: Description of state of nutrition.
- at0059::Well nourished [Subject is well-nourished but not overweight.]
- at0060::Under nourished [Subject appears under-nourished.]
- at0066::Cachectic [Subject appears to have general wasting.]
- at0056::Morbidly obese [Subject is overweight to the point of ill health.]
- at0055::Obese [Subject appears overweight.]
- at0068::Anorexic [Subject appears morbidly thin.]
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| Physique | Physique: Description of physical stature.
- at0047::Thin [Subject appears thin.]
- at0048::Tall [Subject appears taller than average.]
- at0049::Short [Subject appears smaller than average.]
- at0050::Normal weight for height [Subject appears to have normal weight for height.]
- at0051::Slightly overweight for height [Subject appears slightly overweight for height.]
- at0052::Slightly underweight for height [Subject appears slightly underweight for height.]
- at0053::Overweight for height [Subject appears overweight for height.]
- at0054::Underweight for height [Subject appears underweight for height.]
- at0057::Average height [Subject appears to be of average height.]
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| Posture | Posture: Description of posture. |
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| Self care | Self care: Inspection of patient's hygiene. |
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| Cleanliness | Cleanliness: Subjective description of cleanliness. |
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| Grooming | Grooming: Subjective description of patient's grooming. |
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| Odour | Odour: Subjective description of patient's body odour, with respect to self-care. |
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| State of dress | State of dress: Description of patient's state and condition of clothing. |
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| Behaviour | Behaviour: Description of observed behaviours. |
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| Mood description | Mood description: Description of readily apparent mood disturbance. |
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| Unusual behaviour details | Unusual behaviour details: Description of observed unusual, abnormal or inappropriate behaviour. |
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| Function | Function: General aspect of subject's function. |
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| Speech | Speech: Clinical descripton of speech. |
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| Involuntary movements | Involuntary movements: Clinical description of generalised abnormal body movements. |
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| Handedness | Handedness: Observation of dominant hand.
- at0033::Left-handed [Subject has left-hand dominance.]
- at0034::Right-handed [Subject has right-hand dominance.]
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| Smells of | Smells of: Details of clinically significant smells. |
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| Smell | Smell: The name of the smell.
Choice of:
- Coded Text
- at0126::Smells of alcohol [The subject smells of alcohol.]
- at0127::Smells of ketones [The subject smells of ketones.]
- Text
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| Description | Description: Text description of the smell. |
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| Degree | Degree: The extent of the smell detected.
0: at0099::Absent [The smell is absent.]
1: at0100::Mild [The smell is mild.]
2: at0101::Moderate [The smell is moderate.]
3: at0102::Marked [The smell is strong.]
Assumed value: 0: Absent
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| Body site | Body site: Location of the smell.
Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations |
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| Obvious abnormality on inspection | Obvious abnormality on inspection: Details of other obvious abnormalities by simple inspection.
Include:
openEHR-EHR-CLUSTER.inspection.v1 and specialisations or
openEHR-EHR-CLUSTER.gait.v1 and specialisations or
openEHR-EHR-CLUSTER.issue.v1 and specialisations |
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| Other contributors | Sam Heard, Ocean Informatics, Australia
Ian McNicoll, Ocean Informatics, UK |
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| Translators | |
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