ARCHETYPE Examination of external auditory canal (openEHR-EHR-CLUSTER.exam_auditory_canal.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_auditory_canal.v1
ConceptExamination of external auditory canal
DescriptionFindings observed during the physical examination of the external auditory canal.
UseUse to record a narrative description of the overall findings observed during the physical examination of external auditory canal. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_ears archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, CLUSTER.exam_tympanic_membrane or CLUSTER.exam_middle_ear. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
MisuseNot to be used for recording data not related to other parts of the ear such as the Pinna or Middle ear - use the specific archetypes, CLUSTER.exam_pinna and CLUSTER.exam_middle_ear. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.audiogram_result.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the physical examination of XYZ.
ReferencesDirect communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program.

Northern Territory Government, Department of Health: Hearing Health Program ENT Specialist Consultation Form 2011 12 07.

Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Teleotology Nurse Consultation Form 2011 12 07.

Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Audiologist Consultation Form 2011 12 07.

OATSIH: The Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (2010). Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25792800821BE8?OpenDocument.
Copyright© Northern Territory Department of Health, Australia, openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2012-09-03
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2012-09-03
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, references=Direct communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program. Northern Territory Government, Department of Health: Hearing Health Program ENT Specialist Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Teleotology Nurse Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Audiologist Consultation Form 2011 12 07. OATSIH: The Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (2010). Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25792800821BE8?OpenDocument., original_namespace=com.oceaninformatics, original_publisher=Ocean Informatics, custodian_namespace=com.oceaninformatics, MD5-CAM-1.0.1=FEB3117E30660226B39CA9E398EF25A7, build_uid=c62dd47f-cdfb-481f-9ae8-2cd66eabf43c, revision=1.0.0}
Keywords
Lifecyclepublished
UID01d5c63a-781a-4612-8da7-14827608c1a5
Language useden
Citeable Identifier1013.1.970
Revision Number1.0.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of the external auditory canal., archetypeConceptComment=null, otherContributors=Heather Leslie, Ocean Informatics, Australia (nehta Editor)
Silje Ljosland Bakke, Bergen Hospital Trust, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway
Stephen Chu, NEHTA, Australia
Harvey Coates, UWA, Australia
Marissa Cookson, Dept of Health, Australia
Kimberley Crebbin, NT Hearing Services, Australia
Graeme Crossland, Northern Territory, Australia
Kathy Currie, Northern Territory Health, Australia
Jacques de Haan, Alice Springs Hospital, Australia
Jade Frederiksen, Hearing Health Program, DoH, Australia
Sam Heard, Ocean Informatics, Australia (Editor)
Paul Hickey, Hearing Health Program, Australia
Oliver Hosking, Remote Health NT, Australia
Amanda Leach, Menzies School of Health Research, Australia
Anthony Leech, Hearing Health, Australia
Kerrie Lee, Ngaanyatjarra Health Service, Australia
Heather Leslie, Ocean Informatics, Australia (Editor)
Ian McNicoll, Ocean Informatics, United Kingdom
Hemi Patel, Royal Darwin Hospital, Australia
Mark Ramjan, NT Department of Health, Australia
Fiona Wake, RAHC, Australia
Christine Wigger, Menzies School of Health Research, Australia, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], activities=[], credentials=[], state=[], capabilities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Ear examined, description=Identification of the ear under examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Left [The left ear was examined.]
  • Right [The right ear was examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination of the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=ELEMENT, level=1, text=Wax description, description=Narrative description of the wax findings in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=Canal tenderness, description=Presence of tenderness in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Tenderness is noted in the external auditory canal wall.]
  • Absent [Tenderness is not noted in the external auditory canal wall.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015], code=at0015, itemType=ELEMENT, level=1, text=Offensive odour, description=Presence of any offensive odour originating from the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [An offensive odour is noted as originating from the external auditory canal.]
  • Absent [No odour is noted as originating from the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Discharge presence, description=Presence of a discharge observed in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Discharge is observed within the ear canal.]
  • Absent [Discharge is not observed within the ear canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0021], code=at0021, itemType=ELEMENT, level=1, text=Discharge type, description=Type of discharge observed in the external auditory canal or at the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Blood-stained [The discharge appears to consist mostly of blood.]
  • Haemoserous [The discharge appears to consist of both blood and clear, watery fluid.]
  • Mucoid [The discharge appears to consist mostly of a thick, mucoid substance]
  • Mucopurulent [The discharge appears to consist of both mucous and pus.]
  • Purulent [The discharge appears to consist mostly of pus.]
  • Serous [The discharge appears to consist mostly of clear, watery fluid.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0028], code=at0028, itemType=ELEMENT, level=1, text=Discharge amount, description=Amount of discharge observed in the external auditory canal or at the tympanic membrane perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Scant [A small amount of discharge is observed in the external auditory canal.]
  • Moderate [A moderate amount of discharge is observed in the external auditory canal.]
  • Profuse [A profuse amount of discharge is observed in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Discharge description, description=Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0033], code=at0033, itemType=ELEMENT, level=1, text=Foreign body presence, description=Presence of a foreign body in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A foreign body is present in the external auditory canal.]
  • Absent [A foreign body is not present in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0036], code=at0036, itemType=ELEMENT, level=1, text=Foreign body location, description=Location of the foreign body within the external auditory canal., comment=This data element is redundant if a foreign body is absent from the canal., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Outer Canal [The foreign body is located in the outer part of the external auditory canal.]
  • Deep Canal [The foreign body is located in the deep, inner part of the external auditory canal.]
  • Middle ear [The foreign body is located within the middle ear cavity.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1 and specialisations Or
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openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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  • Left [The left ear was examined.]
  • Right [The right ear was examined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination of the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=ELEMENT, level=1, text=Wax description, description=Narrative description of the wax findings in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=Canal tenderness, description=Presence of tenderness in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Tenderness is noted in the external auditory canal wall.]
  • Absent [Tenderness is not noted in the external auditory canal wall.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0015], code=at0015, itemType=ELEMENT, level=1, text=Offensive odour, description=Presence of any offensive odour originating from the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [An offensive odour is noted as originating from the external auditory canal.]
  • Absent [No odour is noted as originating from the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Discharge presence, description=Presence of a discharge observed in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Discharge is observed within the ear canal.]
  • Absent [Discharge is not observed within the ear canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0021], code=at0021, itemType=ELEMENT, level=1, text=Discharge type, description=Type of discharge observed in the external auditory canal or at the tympanic membrane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Blood-stained [The discharge appears to consist mostly of blood.]
  • Haemoserous [The discharge appears to consist of both blood and clear, watery fluid.]
  • Mucoid [The discharge appears to consist mostly of a thick, mucoid substance]
  • Mucopurulent [The discharge appears to consist of both mucous and pus.]
  • Purulent [The discharge appears to consist mostly of pus.]
  • Serous [The discharge appears to consist mostly of clear, watery fluid.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0028], code=at0028, itemType=ELEMENT, level=1, text=Discharge amount, description=Amount of discharge observed in the external auditory canal or at the tympanic membrane perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Scant [A small amount of discharge is observed in the external auditory canal.]
  • Moderate [A moderate amount of discharge is observed in the external auditory canal.]
  • Profuse [A profuse amount of discharge is observed in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Discharge description, description=Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0033], code=at0033, itemType=ELEMENT, level=1, text=Foreign body presence, description=Presence of a foreign body in the external auditory canal., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A foreign body is present in the external auditory canal.]
  • Absent [A foreign body is not present in the external auditory canal.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0036], code=at0036, itemType=ELEMENT, level=1, text=Foreign body location, description=Location of the foreign body within the external auditory canal., comment=This data element is redundant if a foreign body is absent from the canal., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Outer Canal [The foreign body is located in the outer part of the external auditory canal.]
  • Deep Canal [The foreign body is located in the deep, inner part of the external auditory canal.]
  • Middle ear [The foreign body is located within the middle ear cavity.]
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openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1 and specialisations Or
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