ARCHETYPE Physical examination findings (openEHR-EHR-OBSERVATION.exam.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.exam.v1
ConceptPhysical examination findings
DescriptionFindings observed during the physical examination of a subject of care.
UseUse 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.
MisuseNot 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.
PurposeFor recording details about findings on physical examination of the subject of care.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-11-10
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-11-10
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Ocean Informatics, current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=CA38F813160C7B970E1C4F6118F74BC7, build_uid=7f19f635-b13f-48cd-a6d3-2037b23f9550, revision=1.0.0}
Keywordsexamination, physical, exam, findings, clinical
Lifecyclepublished
UID8808bc17-0674-4b14-84f2-3d377aed8254
Language useden
Citeable Identifier1013.1.271
Revision Number1.0.0
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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, originalLanguage=en, translators=Spanish (Argentina): Edgardo Vazquez, VinculoMedico, Medical Doctor
Arabic (Syria): Mona Saleh
Slovenian: Uroš Rajkovič, Biljana Prinčič, Slovenia
Chinese (PRC): Lin Zhang, BIPH, linforest@163.com, ?
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