ARCHETYPE Examination of hemorrhoids (openEHR-EHR-CLUSTER.exam_hemorrhoids_v0_1.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_hemorrhoids_v0_1.v0
ConceptExamination of hemorrhoids
DescriptionFindings observed during the physical examination of hemorrhoids.
UseThis archetype is designed to be used in the "Examination findings" SLOT within the OBSERVATION.exam archetype, but can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate - for example, CLUSTER.exam_anus. 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 hemorrhoids. 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.blood_pressure or OBSERVATION.imaging_exam.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the physical examination of hemorrhoids.
References
Copyright© openEHR Foundation
AuthorsForfatternavn: Hallvard Lærum
Organisasjon: Oslo Universitetssykehus HF
E-post: hallaeru@online.no
Opprinnelig skrevet dato: 2015-06-08
Other Details LanguageForfatternavn: Hallvard Lærum
Organisasjon: Oslo Universitetssykehus HF
E-post: hallaeru@online.no
Opprinnelig skrevet dato: 2015-06-08
OtherDetails Language Independent{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=openEHR Foundation, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=B3EAA3B0AF0BECFBF56AD33A506ED4E5, build_uid=4fd3f3e5-ce69-4d48-b2bc-90d083ccd0f4, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDe321315e-026d-48c8-824e-616c30254957
Language useden
Citeable Identifier1078.36.1419
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the physical examination of hemorrhoids., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway
Morten Aas, Oslo University Hospital, Norway, originalLanguage=en, translators=, subjectOfData=ubegrenset, archetypeTranslationTree=null, topLevelToAshis={contacts=[], source=[], ism_transition=[], description=[], protocol=[], credentials=[], target=[], data=[], content=[], other_participations=[], details=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Present?, description=Whether there are found hemorrhoids during examination, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [There were found hemorrhoids]
  • Absent [No hemorrhoids found]
  • Undetermined [It is not possible to decide whether or not there are hemorrhoids]
, 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., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
openEHR-EHR-CLUSTER.multimedia.v1 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0016], code=at0016, itemType=ELEMENT, level=1, text=Quantity, description=The number of hemorrhoids found, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <=100

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=CLUSTER, level=1, text=Appearance, description=A set of properties of each hemorrhoid found, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Alias, description=Optional specific label for the hemorrhoid , comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0018], code=at0018, itemType=ELEMENT, level=2, text=Location, description=Type of hemorrhoid based on location relative to anus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • External [*]
  • Internal [*]
  • Mixed [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0017], code=at0017, itemType=SLOT, level=2, text=Detailed location, description=Detailed anatomical description of a hemorrhoid. Use clock notation for external hemorrhoids, and relative to anus for internal hemorrhoids., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 og spesialiseringer Eller
openEHR-EHR-CLUSTER.anatomical_location_clock.v0 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0022], code=at0022, itemType=ELEMENT, level=2, text=Shape, description=The overall shape of the hemorrhoid., comment=E.g. with stalk, broad based, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0023], code=at0023, itemType=ELEMENT, level=2, text=Grade, description=Description of the severity or stage of the hemorrhoid, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Sharp classification, description=The severity of the hemorrhoid based on the Sharp classification., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • I pale [*]
  • II moderate [*]
  • III Severe [*]
  • IV Necrotic [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Bleeding, description=Narrative description of the degree of bleeding, and how easily the hemorrhoid bleeds., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Tenderness, description=Narrative description of pain and tenderness to touch., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0032], code=at0032, itemType=ELEMENT, level=2, text=Degree of prolapse, description=The degree of prolapse of internal hemorrhoids as described by D. Beck (2011), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Grade I [No prolapse, just prominent blood vessels]
  • Grade II [Prolapse upon bearing down, but spontaneous reduction]
  • Grade III [Prolapse upon bearing down requiring manual reduction]
  • Grade IV [Prolapse with inability to be manually reduced]
, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
Alle ikke eksplisitt ekskluderte arketyper, 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=Valgfritt, gjentagende, 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=Valgfritt, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
openEHR-EHR-CLUSTER.exclusion_exam.v1 og spesialiseringer, extendedValues=null]], relationships=[], activities=[], provider=[], identities=[], state=[], context=[], events=[], capabilities=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obligatorisk, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Present?, description=Whether there are found hemorrhoids during examination, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [There were found hemorrhoids]
  • Absent [No hemorrhoids found]
  • Undetermined [It is not possible to decide whether or not there are hemorrhoids]
, 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., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
openEHR-EHR-CLUSTER.multimedia.v1 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0016], code=at0016, itemType=ELEMENT, level=1, text=Quantity, description=The number of hemorrhoids found, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0; max: <=100

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=CLUSTER, level=1, text=Appearance, description=A set of properties of each hemorrhoid found, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0015], code=at0015, itemType=ELEMENT, level=2, text=Alias, description=Optional specific label for the hemorrhoid , comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0018], code=at0018, itemType=ELEMENT, level=2, text=Location, description=Type of hemorrhoid based on location relative to anus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • External [*]
  • Internal [*]
  • Mixed [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0017], code=at0017, itemType=SLOT, level=2, text=Detailed location, description=Detailed anatomical description of a hemorrhoid. Use clock notation for external hemorrhoids, and relative to anus for internal hemorrhoids., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 og spesialiseringer Eller
openEHR-EHR-CLUSTER.anatomical_location_clock.v0 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0022], code=at0022, itemType=ELEMENT, level=2, text=Shape, description=The overall shape of the hemorrhoid., comment=E.g. with stalk, broad based, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0023], code=at0023, itemType=ELEMENT, level=2, text=Grade, description=Description of the severity or stage of the hemorrhoid, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0024], code=at0024, itemType=ELEMENT, level=2, text=Sharp classification, description=The severity of the hemorrhoid based on the Sharp classification., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • I pale [*]
  • II moderate [*]
  • III Severe [*]
  • IV Necrotic [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Bleeding, description=Narrative description of the degree of bleeding, and how easily the hemorrhoid bleeds., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Tenderness, description=Narrative description of pain and tenderness to touch., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014]/items[at0032], code=at0032, itemType=ELEMENT, level=2, text=Degree of prolapse, description=The degree of prolapse of internal hemorrhoids as described by D. Beck (2011), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Grade I [No prolapse, just prominent blood vessels]
  • Grade II [Prolapse upon bearing down, but spontaneous reduction]
  • Grade III [Prolapse upon bearing down requiring manual reduction]
  • Grade IV [Prolapse with inability to be manually reduced]
, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
Alle ikke eksplisitt ekskluderte arketyper, 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=Valgfritt, gjentagende, 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=Valgfritt, 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=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
openEHR-EHR-CLUSTER.exclusion_exam.v1 og spesialiseringer, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]