| ARCHETYPE ID | openEHR-EHR-OBSERVATION.exam.v1 |
|---|---|
| Concept | Physical examination findings |
| Description | Findings observed during the physical examination of a subject of care. |
| Use | Use to record details about findings on physical examination of the subject of care. This may include a narrative description of the findings, a framework in which to nest detailed CLUSTER examination archetypes, and a clinical interpretation of the findings. Examples of detailed CLUSTER examination archetypes include those that describe inspection, palpation, auscultation, percussion and movement of body systems or anatomical structures, such as CLUSTER.exam_pupils. Narrative descriptions of clinical findings from existing clinical systems may be captured using the 'Description' data element. Clinicians may sometimes want to record a summative phrase such as 'chronic otitis media' as an Interpretation of the physical examination. In the context of the physical examination archetype this should only be understood as 'physical signs are consistent with chronic otitis media'. While the summative phrase may appear to represent a diagnosis, safe and consistent querying requires a diagnosis to be recorded using the EVALUATION.problem_diagnosis archetype, even if the phrases are identical. |
| Misuse | Not to be used for recording history-taking observations - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure, OBSERVATION.body_weight, or OBSERVATION.height. |
| Purpose | For recording details about findings on physical examination of the subject of care. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2007-11-10 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2007-11-10 |
| Other Details (Language Independent) |
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| Keywords | examination, physical, exam, findings, clinical |
| Lifecycle | published |
| UID | 8808bc17-0674-4b14-84f2-3d377aed8254 |
| Language used | en |
| Citeable Identifier | 1013.1.271 |
| Revision Number | 1.0.0 |
| state | |
| Confounding factors | Confounding factors: Description of any incidental factors that may have contributed to the physical examination findings. |
| events | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| protocol | |
| Device details | Device details: Details about any device used during the physical examination. Include: openEHR-EHR-CLUSTER.device.v1 and specialisations |
| Extension | Extension: Additional information required to capture local content or to align with other reference models/formalisms. e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents. Include: All not explicitly excluded archetypes |
| data | |
| Description | Description: Narrative description of the overall findings observed during a physical examination of a patient. May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format. |
| Examination detail | Examination detail: Structured details of the physical examination. Detailed clinical findings will be recorded as CLUSTER archetypes which can be nested within this SLOT to represent the fractal nature of clinical examination and allow for variation in clinician's requirements for examination documentation. For example: CLUSTER.palpation_of_uterus, CLUSTER.palpation_of_cervix and CLUSTER.palpation_of_fetus can be nested in this slot or within each other to represent the specific requirements of clinicians working in the obstetric domains - content, priorities and level of detail will differ depending on clinical context, professional background and specialty. Include: All not explicitly excluded archetypes |
| Interpretation | Interpretation: Single word, phrase or brief description which represents the clinical meaning and significance of the physical examination findings. Coding with a terminology is preferred, if possible. For example, 'normal examination' or 'tympanic membrane perforation'. |
| Comment | Comment: Additional narrative about the overall physical examination findings not captured in other fields. |
| Other contributors | Sheryl Alexander, NT Department of Health, Australia Tomas Alme, DIPS, Norway Nadim Anani, Karolinska Institutet, Sweden Rita Apelt, Department of Health,NT, Australia Silje Bakke, Bergen Hospital Trust, Norway Margaret Campbell, Queensland Health, Australia Rong Chen, Cambio Healthcare Systems, Sweden Stephen Chu, NeHTA, Australia Margaret Cotter, AMSANT, Australia Michelle Dowden, Miwatj Health Ngalkanbuy Health, Australia Samo Drnovsek, Marand ltd, Slovenia Tim Garden, NTG Department of Health, Australia Tanya Gardner, CAAC, Australia Sam Heard, Ocean Informatics, Australia (Editor) Lars Karlsen, DIPS ASA, Norway Russell Leftwich, Russell B Leftwich MD, United States Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway Heather Leslie, Ocean Informatics, Australia (Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (Editor) Jeremy Oats, NT Health, Australia Steven Schatz, Department of Health (Northern Territory), Australia Anoop Shah, University College London, United Kingdom Cherie Whitbread, Royal Darwin Hospital, Australia Jo Wright, NT Dept of Health, Australia (Editor) Lin Zhang, BIPH, China |
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