| TEMPLATE ID | *CL 3.1.3 Otoscopy Report |
|---|---|
| Concept | *CL 3.1.3 Otoscopy Report |
| Description | To record the findings on examination of the external auditory canal and tympanic membrane using otoscopy |
| Purpose | To record the findings on examination of the external auditory canal and tympanic membrane using otoscopy |
| References | |
| Other Details (Language Independent) |
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| Language used | en |
| Citeable Identifier | 1013.26.799 |
| Root archetype id | openEHR-EHR-COMPOSITION.report-result.v1 |
| Otoscopy Report | Otoscopy Report: Document to communicate information to others about the result of a test or assessment. |
| Other Context | |
| Report ID | Report ID: Identification information about the report. |
| Status | Status: The status of the entire report. Note: This is not the status of any of the report components. |
| Otoscopy findings | Otoscopy findings: Findings observed during the physical examination of a subject of care. |
| Baseline | Baseline: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Examination of Ears | Examination of Ears: Findings observed during the physical examination of the ears. |
| Clinical description | Clinical description: Narrative description of the overall findings observed during a physical examination of the ears. May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, 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. |
| Per ear | Per ear: Details about physical examination findings for the identified ear. Name of the |
| Side | Side: *
|
| No abnormality detected | No abnormality detected: Statement that no abnormality was detected (NAD) on overall examination of the right ear. |
| Examination of external auditory canal | Examination of external auditory canal: Findings observed during the physical examination of the external auditory canal. |
| 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. |
| Other findings | Other findings: 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. |
| Discharge presence | Discharge presence: Presence of a discharge observed in the external auditory canal.
|
| Discharge type | Discharge type: Type of discharge observed in the external auditory canal or at the tympanic membrane.
|
| Discharge amount | Discharge amount: Amount of 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.
|
| 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.
|
| Examination of tympanic membrane | Examination of tympanic membrane: Findings observed during the physical examination of the tympanic membrane . |
| View | View: Description about the examiner's view of the tympanic membrane.
|
| Reason for occlusion | Reason for occlusion: Narrative description of the reason for occlusion of view of the tympanic membrane. |
| Ventilation tube present? | Ventilation tube present?: Is a ventilation tube observed in the tympanic membrane?
|
| Ventilation tube position | Ventilation tube position: Observed position of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal.
|
| Ventilation tube description | Ventilation tube description: Narrative description about the appearance of the ventilation tubes. |
| Membrane intact? | Membrane intact?: Is the tympanic membrane intact?
|
| Appearance | Appearance: Category describing the appearance of the tympanic membrane.
|
| Colour | Colour: Description of the overall colour of the tympanic membrane. |
| Light reflex | Light reflex: Is a normal light reflex observed?
|
| Surface features | Surface features: Features observed on the surface of the tympanic membrane. This data element has multiple occurrences to enable multiple selections, if required. In most situations, this data element would only be recorded if the tympanic membrane is intact. Annotations
|
| Location of tympanosclerosis | Location of tympanosclerosis: Description of the location of any tympanosclerosis observed on the tympanic membrane. |
| Position of tympanic membrane | Position of tympanic membrane: Description of the position of the tympanic membrane.
|
| Retraction description | Retraction description: Narrative description of the retraction of the tympanic membrane. |
| Sade Classification | Sade Classification: Grading of the degree of tympanic membrane pars tensa retraction / atelectasis. |
| Sade Classification | Sade Classification: Grading of the degree of tympanic membrane pars tensa retraction / atelectasis based on the Sade Classification.
|
| Tos Classification | Tos Classification: A classification of the degree of tympanic membrane pars flaccida retraction, related to extent and severity and as described by Tos and Poulsen. |
| Tos Classification | Tos Classification: Grading of the degree of tympanic membrane pars tensa retraction / atelectasis based on the Tos & Poulson Classification.
|
| Fluid level presence | Fluid level presence: Observation of a fluid level behind the tympanic membrane.
|
| Fluid level description | Fluid level description: Narrative description of the fluid level and other related features observed behind the tympanic membrane. |
| Mobility | Mobility: Description of mobility of the tympanic membrane. Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobility (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set.
|
| Perforation details | Perforation details: Details about a perforation in the tympanic membrane. |
| Perforation description | Perforation description: Narrative description of the perforation of the tympanic membrane. |
| Estimation of size | Estimation of size: Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks.
|
| Intermediate estimation | Intermediate estimation: Further detail about the size of an intermediate perforation.
|
| Pars flaccida vs pars tensa? | Pars flaccida vs pars tensa?: Description of the region of the tympanic membrane perforation. To document explicitly whether the perforation is located in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant. Coding with a terminology is preferred, if possible.
|
| Marginal vs central? | Marginal vs central?: Location of the tympanic membrane perforation. To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant.
|
| Anterior? | Anterior?: Is an anterior perforation present? To document the presence of perforation in the anterior portions of the pars tensa, whcih can be more difficult to manage than perforations elsewhere. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant.
|
| Edge | Edge: Narrative description of the edge of the perforation. |
| Multimedia Resource | Multimedia Resource: Details about an multimedia representation of the clinical data. |
| Multimedia resource | Multimedia resource: Multimedia representation of the clinical observation or finding. |
| Title | Title: Name of the multimedia resource. |
| Description | Description: Narrative description of the multimedia resource. |
| Source | Source: The source of the multimedia resource. |
| Date created | Date created: Date/time that the multimedia resource was created. |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings. |
| Exclusion of examination | Exclusion of examination: Positive statement to record that the physical examination, or a specified part of the physical examination, was not performed. |
| Examination not done | Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints. Annotations
|
| Exclusion of examination | Exclusion of examination: Positive statement to record that the physical examination, or a specified part of the physical examination, was not performed. |
| Examination not done | Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints. Annotations
|
| Multimedia representation | Multimedia representation: Digital image or video taken, or a diagram drawn, during the physical examination of the ears. |
| Confounding factors | Confounding factors: Description of any incidental factors that may have contributed to the physical examination findings. |
| Post Cleaning | Post Cleaning: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Examination of Ears | Examination of Ears: Findings observed during the physical examination of the ears. |
| Clinical description | Clinical description: Narrative description of the overall findings observed during a physical examination of the ears. May be used to record a narrative summary of the complete clinical examination of the body system or anatomical strucutre or key aspects of physical examination findings, which will be further supported by the additional structured data, 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. |
| Per ear | Per ear: Details about physical examination findings for the identified ear. Name of the |
| Side | Side: *
|
| No abnormality detected | No abnormality detected: Statement that no abnormality was detected (NAD) on overall examination of the right ear. |
| Examination of external auditory canal | Examination of external auditory canal: Findings observed during the physical examination of the external auditory canal. |
| 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. |
| Other findings | Other findings: 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. |
| Discharge presence | Discharge presence: Presence of a discharge observed in the external auditory canal.
|
| Discharge type | Discharge type: Type of discharge observed in the external auditory canal or at the tympanic membrane.
|
| Discharge amount | Discharge amount: Amount of 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.
|
| 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.
|
| Examination of tympanic membrane | Examination of tympanic membrane: Findings observed during the physical examination of the tympanic membrane . |
| View | View: Description about the examiner's view of the tympanic membrane.
|
| Reason for occlusion | Reason for occlusion: Narrative description of the reason for occlusion of view of the tympanic membrane. |
| Ventilation tube present? | Ventilation tube present?: Is a ventilation tube observed in the tympanic membrane?
|
| Ventilation tube position | Ventilation tube position: Observed position of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal.
|
| Ventilation tube description | Ventilation tube description: Narrative description about the appearance of the ventilation tubes. |
| Membrane intact? | Membrane intact?: Is the tympanic membrane intact?
|
| Appearance | Appearance: Category describing the appearance of the tympanic membrane.
|
| Colour | Colour: Description of the overall colour of the tympanic membrane. |
| Light reflex | Light reflex: Is a normal light reflex observed?
|
| Surface features | Surface features: Features observed on the surface of the tympanic membrane. This data element has multiple occurrences to enable multiple selections, if required. In most situations, this data element would only be recorded if the tympanic membrane is intact. Annotations
|
| Location of tympanosclerosis | Location of tympanosclerosis: Description of the location of any tympanosclerosis observed on the tympanic membrane. |
| Position of tympanic membrane | Position of tympanic membrane: Description of the position of the tympanic membrane.
|
| Retraction description | Retraction description: Narrative description of the retraction of the tympanic membrane. |
| Sade Classification | Sade Classification: Grading of the degree of tympanic membrane pars tensa retraction / atelectasis. |
| Sade Classification | Sade Classification: Grading of the degree of tympanic membrane pars tensa retraction / atelectasis based on the Sade Classification.
|
| Tos Classification | Tos Classification: A classification of the degree of tympanic membrane pars flaccida retraction, related to extent and severity and as described by Tos and Poulsen. |
| Tos Classification | Tos Classification: Grading of the degree of tympanic membrane pars tensa retraction / atelectasis based on the Tos & Poulson Classification.
|
| Fluid level presence | Fluid level presence: Observation of a fluid level behind the tympanic membrane.
|
| Fluid level description | Fluid level description: Narrative description of the fluid level and other related features observed behind the tympanic membrane. |
| Mobility | Mobility: Description of mobility of the tympanic membrane. Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobility (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set.
|
| Perforation details | Perforation details: Details about a perforation in the tympanic membrane. |
| Perforation description | Perforation description: Narrative description of the perforation of the tympanic membrane. |
| Estimation of size | Estimation of size: Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks.
|
| Intermediate estimation | Intermediate estimation: Further detail about the size of an intermediate perforation.
|
| Pars flaccida vs pars tensa? | Pars flaccida vs pars tensa?: Description of the region of the tympanic membrane perforation. To document explicitly whether the perforation is located in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant. Coding with a terminology is preferred, if possible.
|
| Marginal vs central? | Marginal vs central?: Location of the tympanic membrane perforation. To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant.
|
| Anterior? | Anterior?: Is an anterior perforation present? To document the presence of perforation in the anterior portions of the pars tensa, whcih can be more difficult to manage than perforations elsewhere. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant.
|
| Edge | Edge: Narrative description of the edge of the perforation. |
| Multimedia Resource | Multimedia Resource: Details about an multimedia representation of the clinical data. |
| Multimedia resource | Multimedia resource: Multimedia representation of the clinical observation or finding. |
| Title | Title: Name of the multimedia resource. |
| Description | Description: Narrative description of the multimedia resource. |
| Source | Source: The source of the multimedia resource. |
| Date created | Date created: Date/time that the multimedia resource was created. |
| Exclusion of examination | Exclusion of examination: Positive statement to record that the physical examination, or a specified part of the physical examination, was not performed. |
| Examination not done | Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints. Annotations
|
| Exclusion of examination | Exclusion of examination: Positive statement to record that the physical examination, or a specified part of the physical examination, was not performed.Annotations
|
| Examination not done | Examination not done: Statement to explicity record that the examination was not performed. Record as True if the examination was not performed. |
| Reason | Reason: Reason for the 'not done' statement. For example: patient factors, equipment factors, time constraints. |
| Multimedia representation | Multimedia representation: Digital image or video taken, or a diagram drawn, during the physical examination of the ears. |
| Confounding factors | Confounding factors: Description of any incidental factors that may have contributed to the physical examination findings. |
| Protocol | |
| Otoscopy Device | Otoscopy Device: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements. |
| Device name | Device name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device. This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available. Annotations
|