| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_hemorrhoids_v0_1.v0 |
|---|---|
| Concept | Examination of hemorrhoids |
| Description | Findings observed during the physical examination of hemorrhoids. |
| Use | This 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. |
| Misuse | Not 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. |
| Purpose | For recording a narrative description and clinical interpretation of the findings observed during the physical examination of hemorrhoids. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Forfatternavn: Hallvard Lærum Organisasjon: Oslo Universitetssykehus HF E-post: hallaeru@online.no Opprinnelig skrevet dato: 2015-06-08 |
| Other Details Language | Forfatternavn: Hallvard Lærum Organisasjon: Oslo Universitetssykehus HF E-post: hallaeru@online.no Opprinnelig skrevet dato: 2015-06-08 |
| Other Details (Language Independent) |
|
| Keywords | |
| Lifecycle | in_development |
| UID | e321315e-026d-48c8-824e-616c30254957 |
| Language used | en |
| Citeable Identifier | 1078.36.1419 |
| Revision Number | 0.0.1-alpha |
| items | |
| Present? | Present?: Whether there are found hemorrhoids during examination
|
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Inkluder: openEHR-EHR-CLUSTER.multimedia.v1 og spesialiseringer |
| Quantity | Quantity: The number of hemorrhoids found min: >=0; max: <=100 |
| Appearance | Appearance: A set of properties of each hemorrhoid found |
| Alias | Alias: Optional specific label for the hemorrhoid |
| Location | Location: Type of hemorrhoid based on location relative to anus.
|
| Detailed location | Detailed location: Detailed anatomical description of a hemorrhoid. Use clock notation for external hemorrhoids, and relative to anus for internal hemorrhoids. Inkluder: openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ |
| Shape | Shape: The overall shape of the hemorrhoid. E.g. with stalk, broad based |
| Grade | Grade: Description of the severity or stage of the hemorrhoid |
| Sharp classification | Sharp classification: The severity of the hemorrhoid based on the Sharp classification.
|
| Bleeding | Bleeding: Narrative description of the degree of bleeding, and how easily the hemorrhoid bleeds. |
| Tenderness | Tenderness: Narrative description of pain and tenderness to touch. |
| Degree of prolapse | Degree of prolapse: The degree of prolapse of internal hemorrhoids as described by D. Beck (2011)
|
| Examination findings | Examination findings: Structured details about the physical examination findings. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| 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. Inkluder: openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | Vebjørn Arntzen, Oslo University Hospital, Norway Morten Aas, Oslo University Hospital, Norway |
| Translators |