ARCHETYPE Examination of body fluid (openEHR-EHR-CLUSTER.exam_body_fluid_v0_8.v0)

Use to record a narrative description and structured details about findings observed during the examination of any body fluid from an identified body site or source. In addition, use to record the clinical interpretation of the findings.

This archetype has been specifically designed to be used as the framework for recording any body fluid. Findings that are applicable for specified body fluid should be modelled into a separate CLUSTER archetype and nested in the 'Specific findings' SLOT found within this archetype.

Body fluid is a liquid that originates from inside the human body, and this archetype is intended to support detailed description of:

• normal physiological fluids;
• physiological fluids that may be altered due to a pathological process; and
• fluids generated as part of a pathological process within the body.

Examples include, but are not limited to:

• Amniotic fluid;
• Blood and plasma;
• Cerebrospinal fluid;
• Discharge
• Excreta, including urine and liquid faeces;
• Pus;
• Saliva;
• Sputum;
• Synovial fluid;
• Sweat; and
• Vomitus.

While this archetype will most likely be used in the context of a living subject, it is also appropriate to use in recording autopsy findings.

Context of the body site or source will usually be carried in the archetypes in which it is nested, including but not limited to:

• in the 'Examination findings' SLOT within many of the CLUSTER.exam family of archetypes and related inspection and palpation archetypes;
• in the 'Additional details' SLOT within the OBSERVATION.urinalysis, the OBSERVATION.fluid_output archetypes;
• in the and
• within other OBSERVATION or CLUSTER archetypes, where clinically appropriate.

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.

• Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.
• Custodian Organisation: Nasjonal IKT
• References: Avgrenet fra:
• Current Contact: Heather Leslie, Ocean Informatics
• Original Namespace: no.nasjonalikt
• Original Publisher: Nasjonal IKT
• Custodian Namespace: no.nasjonalikt
• MD5-CAM-1.0.1: E8CD6A6EB08124878F48742C189366D8
• Build Uid: 483b83e1-4b28-4349-b397-e2364900b2af
• Revision: 0.0.1-alpha

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  • at0017::Amniotic fluid [*]
  • at0018::Blood [*]
  • at0019::Plasma [*]
  • at0020::Cerebrospinal fluid [*]
  • at0021::Discharge [*]
  • at0022::Urine [Including urine and liquid faeces]
  • at0024::Liquid faeces [*]
  • at0023::Pus [*]
  • at0025::Saliva [*]
  • at0026::Sputum [*]
  • at0027::Synovial fluid [*]
  • at0028::Sweat [*]
  • at0029::Vomitus [*]

• at0009::Present [The fluid was observed at the body site.]
• at0010::Indeterminate [It was not possible to determine if the fluid was present at the body site.]
• at0011::Not present [The fluid was not present at the body site.]