ARCHETYPE Examination of vagina (openEHR-EHR-CLUSTER.examination_of_vagina_v_0_1.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.examination_of_vagina_v_0_1.v0
ConceptExamination of vagina
DescriptionFindings observed during the physical examination of vagina
UseThis 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. 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 examination of vagina 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 vagina
ReferencesAvgrenet fra: <Legg til en referanse til den originale ressursen her>
Copyright© openEHR Foundation, Nasjonal IKT HF
AuthorsForfatternavn: Morten Aas
Organisasjon: Oslo Universitetssykehus
E-post: uxaort@ous-hf.no
Opprinnelig skrevet dato: 2016-05-09
Other Details LanguageForfatternavn: Morten Aas
Organisasjon: Oslo Universitetssykehus
E-post: uxaort@ous-hf.no
Opprinnelig skrevet dato: 2016-05-09
Other Details (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: C5D33D4869BA5B5CF8C236D6DA96EF5D
  • Build Uid: 8cd0beda-713a-4d9d-bd89-0c1095e4b232
  • Revision: 0.0.1
Keywords
Lifecyclerejected
UID00d1ab83-d092-462a-985d-0a577fd402b5
Language useden
Citeable Identifier1078.36.1443
Revision Number0.0.1
items
No abnormality detectedNo 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 descriptionClinical description: Narrative description of the overall findings observed during the physical examination.
Examination findingsExamination findings: Structured details about the physical examination findings.
Inkluder:
Alle ikke eksplisitt ekskluderte arketyper
Multimedia representationMultimedia representation: Digital image, video or diagram representing the physical examination findings.
Inkluder:
openEHR-EHR-CLUSTER.multimedia.v1 og spesialiseringer
Clinical interpretationClinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
CommentComment: Additional narrative about the physical examination findings, not captured in other fields.
Exam not doneExam not done: Details to explicitly record that this examination was not performed.
Inkluder:
openEHR-EHR-CLUSTER.exclusion_exam.v1 og spesialiseringer
Other contributorsVebjørn Arntzen, Oslo Universitetssykehus
Translators