| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam_rectal_exploration_v0_8.v0 |
|---|---|
| Concept | Examination by rectal exploration |
| Description | Findings observed during the physical examination of rectal exploration |
| Use | This archetype has been specifically designed to be used in the 'Examination detail' 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 the physical examination of rectal exploration. 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 rectal exploration. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Forfatternavn: Morten Aas Organisasjon: Oslo Universitetssykehus, Norway E-post: uxaort@ous-hf.no Opprinnelig skrevet dato: 2015-06-08 |
| Other Details Language | Forfatternavn: Morten Aas Organisasjon: Oslo Universitetssykehus, Norway E-post: uxaort@ous-hf.no Opprinnelig skrevet dato: 2015-06-08 |
| Other Details (Language Independent) |
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| Keywords | |
| Lifecycle | in_development |
| UID | 5c1648f9-6bfb-463c-9feb-9e358dd1a59a |
| Language used | en |
| Citeable Identifier | 1078.36.1422 |
| Revision Number | 0.0.1-alpha |
| items | |
| 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. Tillatte verdier: {true} |
| Clinical description | Clinical description: Narrative description of the overall findings observed during the physical examination. |
| Examination findings | Examination findings: Structured details about the physical examination findings. Inkluder: Alle ikke eksplisitt ekskluderte arketyper |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the physical examination findings. Inkluder: openEHR-EHR-CLUSTER.multimedia.v1 og spesialiseringer |
| 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 | Hallvar Lærum, Oslo Universitetssykehus, Norway Vebjørn Arntzen, Oslo Universitetssykehus, Norway |
| Translators |