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

ARCHETYPE IDopenEHR-EHR-CLUSTER.inspection-skin-scalp.v1
ConceptInspection of scalp
DescriptionThe findings on inspection of the scalp
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
Other Details (Language Independent)
  • References:
Keywordsinspect, visual, skin
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.264
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
Skin FindingsSkin Findings: Specific findings on inspection
MethodMethod: Record of findings on inspection using a specific method
  • Direct visualisation [Macroscopic; By eye]
  • Wood's lamp [*]
  • Dermatoscope [*]
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
SurfaceSurface: A description of the surface
ThicknessThickness: Thickness of skin
  • Thickened [*]
  • Normal [*]
  • Thinned/Atrophic [*]
SurroundsSurrounds: Description of immediate surrounds to object
PigmentationPigmentation: Pigmentation of skin
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
HairHair: *
Clinical DescriptionClinical Description: *
ColourColour: Natural colour of hair
Distribution of hairDistribution of hair: Pattern or distribution of hair
Thickness of hairThickness of hair: *
DrawingDrawing: A drawing of the findings on inspection
image/cgm, image/gif, image/png, image/tiff, image/jpeg
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