| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_auditory_canal.v1 |
|---|---|
| Concept | Examination of external auditory canal |
| Description | Findings observed during the physical examination of the external auditory canal. |
| Use | Use 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. |
| Misuse | Not 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. |
| Purpose | For recording a narrative description and clinical interpretation of the findings observed during the physical examination of XYZ. |
| 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. |
| Copyright | © Northern Territory Department of Health, Australia, openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2012-09-03 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2012-09-03 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | published |
| UID | 01d5c63a-781a-4612-8da7-14827608c1a5 |
| Language used | en |
| Citeable Identifier | 1013.1.970 |
| Revision Number | 1.0.0 |
| items | |
| Ear examined | Ear examined: Identification of the ear under examination.
|
| No abnormality detected | No abnormality detected: Statement that no abnormality was detected (NAD) on physical examination. Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. Allowed values: {true} |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination of the external auditory canal. |
| Wax description | Wax description: Narrative description of the wax findings in the external auditory canal. |
| Canal tenderness | Canal tenderness: Presence of tenderness in the external auditory canal.
|
| Offensive odour | Offensive odour: Presence of any offensive odour originating from the external auditory canal.
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| Discharge presence | Discharge presence: Presence of a discharge observed in the external auditory canal.
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| Discharge type | Discharge type: Type of discharge observed in the external auditory canal or at the tympanic membrane.
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| Discharge amount | Discharge amount: Amount of discharge observed in the external auditory canal or at the tympanic membrane perforation.
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| Discharge description | Discharge description: Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation. |
| Foreign body presence | Foreign body presence: Presence of a foreign body in the external auditory canal.
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| Foreign body location | Foreign body location: Location of the foreign body within the external auditory canal. This data element is redundant if a foreign body is absent from the canal.
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| Examination findings | Examination findings: Structured details about the physical examination findings. Include: openEHR-EHR-CLUSTER.exam_ openEHR-EHR-CLUSTER.exam_ |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Include: openEHR-EHR-CLUSTER.multimedia.v1 and specialisations |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. |
| Comment | Comment: Additional narrative about the physical examination findings, not captured in other fields. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | 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 |
| Translators |