ARCHETYPE Examination of an insertion site (openEHR-EHR-CLUSTER.exam_insertion_site.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam_insertion_site.v0
ConceptExamination of an insertion site
DescriptionFindings observed during the physical examination of an insertion site.
UseUse to record a narrative description of the overall findings observed during the physical examination of an insertion site. 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 detail' SLOT within the OBSERVATION.exam archetype, but can also be used within other OBSERVATION or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, CLUSTER.exam_ABC. 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 the physical examination of an insertion site. 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 an insertion site.
References
Copyright© openEHR Foundation, Nasjonal IKT HF
AuthorsForfatternavn: Silje Ljosland Bakke
Organisasjon: Nasjonal IKT HF
E-post: silje.ljosland.bakke@nasjonalikt.no
Opprinnelig skrevet dato: 2016-09-07
Other Details LanguageForfatternavn: Silje Ljosland Bakke
Organisasjon: Nasjonal IKT HF
E-post: silje.ljosland.bakke@nasjonalikt.no
Opprinnelig skrevet dato: 2016-09-07
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=Nasjonal IKT, original_namespace=no.nasjonalikt, original_publisher=Nasjonal IKT, custodian_namespace=no.nasjonalikt, MD5-CAM-1.0.1=6FF5C4121AD2DCB60A6302B848F944DD, build_uid=f67d44d0-8348-449b-9940-fbd1df454cab, revision=0.0.1}
Keywords
Lifecyclerejected
UID083933ca-c201-4b89-9849-180d1bf3433a
Language useden
Citeable Identifier1078.36.1511
Revision Number0.0.1
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Heather Leslie, Ocean Informatics, Australia
Gro Hilde Ulriksen, Universitetssykehuset Nord-Norge HF, Norway
Kristian Berg, Universitetssykehuset Nord-Norge HF, Norway
Anine Ramberg, DIPS ASA, Norway
Phuong Pedersen, DIPS ASA, Norway
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway, originalLanguage=en, translators=, subjectOfData=ubegrenset, archetypeTranslationTree=null, topLevelToAshis={relationships=[], other_participations=[], ism_transition=[], source=[], activities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Insertion site examined, description=Identification of the insertion site under 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[at0012], code=at0012, itemType=ELEMENT, level=1, text=Alias, description=Identification, by using a alias name, of the insertion site to distinguish one insertion site from another at the same body site., comment=For example, 'Drain #1' marked on the inserted device., 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 insertion site, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Valgfritt, gjentagende, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Inkluder:
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