ARCHETYPE Undersøkelse av en lesjon (openEHR-EHR-CLUSTER.exam_lesion_v0_8.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_lesion_v0_8.v0
ConceptUndersøkelse av en lesjon
DescriptionBeskrivelse av en lokalisert endring i normalutseende av hud eller slimhinne.
Use*Use to record a narrative description of the overall findings observed during the physical examination of an identified lesion. This initial draft archetype consists only of the core examination pattern data elements (as per CLUSTER.exam_pattern) and will likely be expanded further over time as specific clinical requirements are identified. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_skin archetype or the OBSERVATION.exam, but can also be used within any other OBSERVATION or CLUSTER archetypes, where clinically appropriate - for example, CLUSTER.exam_breast or CLUSTER.exam_penis. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. 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.(en)
Misuse*Not to be used for recording data not related to the physical examination of an identified lesion. 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. Not to be used to record description of morphologic changes in organs as viewed peroperatively or by endoscopy(en)
Purpose*For recording a narrative description and clinical interpretation of the findings observed during the physical examination of an identified lesion.(en)
ReferencesAvgrenet fra: <Legg til en referanse til den originale ressursen her>
Copyright© *© openEHR Foundation(en), Nasjonal IKT HF
AuthorsForfatternavn: Heather Leslie
Organisasjon: Ocean Informatics
E-post: heather.leslie@oceaninformatics.com
Opprinnelig skrevet dato: 2015-06-25
Other Details LanguageForfatternavn: Heather Leslie
Organisasjon: Ocean Informatics
E-post: heather.leslie@oceaninformatics.com
Opprinnelig skrevet dato: 2015-06-25
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=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=5C9999EF074AAB76A52EA206B2B795F7, build_uid=5947df39-f37b-40e0-822b-a883446beacb, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID63993279-c952-472b-8180-9c2e0ed52b23
Language usednb
Citeable Identifier1078.36.1423
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Beskrivelse av en lokalisert endring i normalutseende av hud eller slimhinne. , archetypeConceptComment=*The lesion may appear on skin or mucosa.(en), otherContributors=Silje Ljosland Bakke, Bergen Hospital Trust, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway
Heather Leslie, Ocean Informatics, Australia
Vebjørn Arntzen, Oslo University Hospital, Norway
Hallvard Lærum, Oslo University Hospital, originalLanguage=en, translators=
  • Norwegian Bokmål: ?

    • , subjectOfData=ubegrenset, archetypeTranslationTree=null, topLevelToAshis={activities=[], target=[], protocol=[], content=[], contacts=[], ism_transition=[], description=[], details=[], data=[], other_participations=[], provider=[], credentials=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=*Lesion type(en), description=*Identification of the type of lesion found on physical examination.(en), comment=*For example, mole, papilloma or depigmented area. (en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Mulige datatyper:
    •  Fri eller kodet tekst
    •  Kodet tekst
      • *Warts(en) [**(en)]
      • *Blister/Vesicles(en) [**(en)]
      • *Ulcers/Sores(en) [**(en)]
      • *Molluscum contagiosa(en) [**(en)]
      • *Spots(en) [**(en)]
      • *Folliculitis(en) [**(en)]
      • *Papules(en) [**(en)]
      • *Macules(en) [**(en)]
      • *Pustules(en) [**(en)]
      • *Papillomatosis(en) [**(en)]
      • *Fissures(en) [**(en)]
      • *Erosions(en) [**(en)]
      • *Erythema(en) [**(en)]
      • *Tumor(en) [**(en)]
      • *Exanthem(en) [**(en)]
      • *Lice(en) [**(en)]
      • *Scabies(en) [**(en)]
      • *Naevi(en) [**(en)]
      • *Petechiae(en) [**(en)]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0033], code=at0033, itemType=ELEMENT, level=1, text=*Presence(en), description=*True if the lesion type is not present.(en), 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(en) [**(en)]
    • *Indeterminate(en) [**(en)]
    • *Absent(en) [**(en)]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=*Alias(en), description=*Identification, by using a alias name, of the lesion to distinguish one lesion from similar lesions at the same body site.(en), comment=*For example, 'Mole #1' as marked on a diagram of the body site.(en), 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[at0003], code=at0003, itemType=ELEMENT, level=1, text=*Clinical description(en), description=*Narrative description of the overall findings observed during the physical examination.(en), 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=*Body site(en), description=*Identification of the body site under examination.(en), comment=*The body site could be on an area of skin or a mucous membrane, for example the right knee, palate or duodenum. If the body site has previously been identified in another archetype in which this archetype is nested, this data element becomes redundant.(en), 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[at0011], code=at0011, itemType=SLOT, level=1, text=*Structured body site(en), description=*A structured anatomical location of the lesion.(en), comment=*If the body site has previously been identified in another archetype in which this archetype is then nested, this SLOT becomes redundant.(en), 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.v1 og spesialiseringer eller
    openEHR-EHR-CLUSTER.anatomical_location_relative.v1 og spesialiseringer eller
    openEHR-EHR-CLUSTER.anatomical_location_clock.v0 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=*Examination findings(en), description=*Structured details about the physical examination findings.(en), 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.dimensions.v1 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=*Multimedia representation(en), description=*Digital image, video or diagram representing the physical examination findings.(en), 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[at0006], code=at0006, itemType=ELEMENT, level=1, text=*Clinical interpretation(en), description=*Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.(en), 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(en), description=*Additional narrative about the physical examination findings, not captured in other fields.(en), 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(en), description=*Details to explicitly record that this examination was not performed.(en), comment=*'Lesion' should be coded with a terminology, where possible.(en), 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]], state=[], context=[], identities=[], relationships=[], events=[], source=[], 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[at0002], code=at0002, itemType=ELEMENT, level=1, text=*Lesion type(en), description=*Identification of the type of lesion found on physical examination.(en), comment=*For example, mole, papilloma or depigmented area. (en), uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Valgfritt, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Mulige datatyper:
    •  Fri eller kodet tekst
    •  Kodet tekst
      • *Warts(en) [**(en)]
      • *Blister/Vesicles(en) [**(en)]
      • *Ulcers/Sores(en) [**(en)]
      • *Molluscum contagiosa(en) [**(en)]
      • *Spots(en) [**(en)]
      • *Folliculitis(en) [**(en)]
      • *Papules(en) [**(en)]
      • *Macules(en) [**(en)]
      • *Pustules(en) [**(en)]
      • *Papillomatosis(en) [**(en)]
      • *Fissures(en) [**(en)]
      • *Erosions(en) [**(en)]
      • *Erythema(en) [**(en)]
      • *Tumor(en) [**(en)]
      • *Exanthem(en) [**(en)]
      • *Lice(en) [**(en)]
      • *Scabies(en) [**(en)]
      • *Naevi(en) [**(en)]
      • *Petechiae(en) [**(en)]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0033], code=at0033, itemType=ELEMENT, level=1, text=*Presence(en), description=*True if the lesion type is not present.(en), 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(en) [**(en)]
    • *Indeterminate(en) [**(en)]
    • *Absent(en) [**(en)]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=*Alias(en), description=*Identification, by using a alias name, of the lesion to distinguish one lesion from similar lesions at the same body site.(en), comment=*For example, 'Mole #1' as marked on a diagram of the body site.(en), 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[at0003], code=at0003, itemType=ELEMENT, level=1, text=*Clinical description(en), description=*Narrative description of the overall findings observed during the physical examination.(en), 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[at0001], code=at0001, itemType=ELEMENT, level=1, text=*Body site(en), description=*Identification of the body site under examination.(en), comment=*The body site could be on an area of skin or a mucous membrane, for example the right knee, palate or duodenum. If the body site has previously been identified in another archetype in which this archetype is nested, this data element becomes redundant.(en), 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[at0011], code=at0011, itemType=SLOT, level=1, text=*Structured body site(en), description=*A structured anatomical location of the lesion.(en), comment=*If the body site has previously been identified in another archetype in which this archetype is then nested, this SLOT becomes redundant.(en), 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.v1 og spesialiseringer eller
    openEHR-EHR-CLUSTER.anatomical_location_relative.v1 og spesialiseringer eller
    openEHR-EHR-CLUSTER.anatomical_location_clock.v0 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=*Examination findings(en), description=*Structured details about the physical examination findings.(en), 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.dimensions.v1 og spesialiseringer, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=*Multimedia representation(en), description=*Digital image, video or diagram representing the physical examination findings.(en), 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[at0006], code=at0006, itemType=ELEMENT, level=1, text=*Clinical interpretation(en), description=*Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.(en), 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(en), description=*Additional narrative about the physical examination findings, not captured in other fields.(en), 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(en), description=*Details to explicitly record that this examination was not performed.(en), comment=*'Lesion' should be coded with a terminology, where possible.(en), 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]