archetype (adl_version=1.4; uid=53ab1c1c-7819-447f-8794-8a9c3ff75821) openEHR-EHR-CLUSTER.exam_tympanic_membrane.v1 concept [at0000] -- Examination of tympanic membrane language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"2012-09-03"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of the tympanic membrane."> use = <"Use to record a narrative description of the overall findings, structured details and clinical interpretation observed during the physical examination of the tympanic membrane. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_auditory_canal archetype, but can also be used within the OBSERVATION.exam and 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_middle_ear. 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."> keywords = <"inspection", "ear", "tympanic", "perforation", "drum", "canal", "otoscopic", "examination", "pneumatic", "otoscopy", "membrane"> misuse = <"Not to be used for recording data not related to other parts of the ear such as the Pinna or Middle ear - use the specific archetypes, CLUSTER.exam_pinna and CLUSTER.exam_middle_ear. 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.audiogram_result."> copyright = <"© Northern Territory Department of Health, Australia, openEHR Foundation"> > > lifecycle_state = <"published"> other_contributors = <"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", "Stephen Chu, NEHTA, Australia", "Harvey Coates, UWA, Australia", "Marissa Cookson, Dept of Health, Australia", "Kimberley Crebbin, NT Hearing Services, Australia", "Graeme Crossland, Northern Territory, Australia", "Kathy Currie, Northern Territory Health, Australia", "Jacques de Haan, Alice Springs Hospital, Australia", "Jade Frederiksen, Hearing Health Program, DoH, Australia", "Sam Heard, Ocean Informatics, Australia (Editor)", "Paul Hickey, Hearing Health Program, Australia", "Oliver Hosking, Remote Health NT, Australia", "Amanda Leach, Menzies School of Health Research, Australia", "Anthony Leech, Hearing Health, Australia", "Kerrie Lee, Ngaanyatjarra Health Service, Australia", "Heather Leslie, Ocean Informatics, Australia (Editor)", "Ian McNicoll, Ocean Informatics, United Kingdom", "Hemi Patel, Royal Darwin Hospital, Australia", "Mark Ramjan, NT Department of Health, Australia", "Fiona Wake, RAHC, Australia", "Christine Wigger, Menzies School of Health Research, Australia"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> ["custodian_organisation"] = <"Ocean Informatics"> ["current_contact"] = <"Heather Leslie, Ocean Informatics"> ["original_namespace"] = <"com.oceaninformatics"> ["original_publisher"] = <"Ocean Informatics"> ["custodian_namespace"] = <"com.oceaninformatics"> ["MD5-CAM-1.0.1"] = <"3D7F37D1F61B8E5C0D531C7137DB7F3D"> ["build_uid"] = <"8be139aa-8f72-47bc-a098-498186318eca"> ["revision"] = <"1.0.0"> > definition CLUSTER[at0000] matches { -- Examination of tympanic membrane items cardinality matches {1..*; unordered} matches { ELEMENT[at0001] occurrences matches {0..1} matches { -- Ear examined value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0009, -- Left at0010] -- Right } } } } ELEMENT[at0002] occurrences matches {0..1} matches { -- No abnormality detected value matches { DV_BOOLEAN matches { value matches {True} } } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } ELEMENT[at0011] occurrences matches {0..1} matches { -- View value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0012, -- Adequate at0013, -- Compromised at0014] -- Total occlusion } } } } ELEMENT[at0015] occurrences matches {0..1} matches { -- Reason for occlusion value matches { DV_TEXT matches {*} } } ELEMENT[at0016] occurrences matches {0..1} matches { -- Ventilation tube present? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0017, -- Present at0018] -- Absent } } } } ELEMENT[at0019] occurrences matches {0..1} matches { -- Ventilation tube position value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0020, -- In situ at0021, -- Partially extruded at0022] -- Extruded - remains in canal } } } } ELEMENT[at0064] occurrences matches {0..1} matches { -- Ventilation tube description value matches { DV_TEXT matches {*} } } ELEMENT[at0023] occurrences matches {0..1} matches { -- Membrane intact? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0024, -- Intact at0026, -- Indeterminate at0025] -- Perforated } } } } ELEMENT[at0027] occurrences matches {0..1} matches { -- Appearance value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0028, -- Translucent at0029] -- Opaque } } } } ELEMENT[at0030] occurrences matches {0..1} matches { -- Colour value matches { DV_TEXT matches {*} } } ELEMENT[at0031] occurrences matches {0..1} matches { -- Light reflex value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0032, -- Normal at0033] -- Abnormal } } } } ELEMENT[at0034] occurrences matches {0..*} matches { -- Surface features value matches { DV_TEXT matches {*} } } ELEMENT[at0035] occurrences matches {0..1} matches { -- Location of tympanosclerosis value matches { DV_TEXT matches {*} } } ELEMENT[at0036] occurrences matches {0..1} matches { -- Position of tympanic membrane value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0037, -- Neutral at0038, -- Retracted at0039, -- Bulging at0040] -- Indeterminate } } } } ELEMENT[at0041] occurrences matches {0..1} matches { -- Retraction description value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0042] occurrences matches {0..*} matches { -- Retraction grade include archetype_id/value matches {/openEHR-EHR-CLUSTER\.sade(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.tos(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0043] occurrences matches {0..1} matches { -- Fluid level presence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0044, -- Present at0045] -- Absent } } } } ELEMENT[at0046] occurrences matches {0..1} matches { -- Fluid level description value matches { DV_TEXT matches {*} } } ELEMENT[at0047] occurrences matches {0..*} matches { -- Mobility value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0048, -- Immobile at0049, -- Hypomobile at0050, -- Mobile at0051, -- Hypermobile at0052] -- Indeterminate } } } } CLUSTER[at0053] occurrences matches {0..*} matches { -- Perforation details items cardinality matches {1..*; unordered} matches { ELEMENT[at0054] occurrences matches {0..1} matches { -- Perforation description value matches { DV_TEXT matches {*} } } ELEMENT[at0055] occurrences matches {0..1} matches { -- Estimation of size value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0056, -- Pinhole at0057, -- Intermediate at0058, -- Subtotal at0059] -- Total } } } } ELEMENT[at0060] occurrences matches {0..1} matches { -- Intermediate estimation value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0061, -- <40% at0062] -- >40% } } } } allow_archetype CLUSTER[at0063] occurrences matches {0..*} matches { -- Measurement include archetype_id/value matches {/openEHR-EHR-CLUSTER\.dimensions(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0065] occurrences matches {0..1} matches { -- Pars flaccida vs pars tensa? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0066, -- Pars flaccida at0067] -- Pars tensa } } } } ELEMENT[at0068] occurrences matches {0..1} matches { -- Marginal vs central? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0069, -- Marginal at0070] -- Central } } } } ELEMENT[at0071] occurrences matches {0..1} matches { -- Anterior? value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0072, -- Present at0073] -- Absent } } } } ELEMENT[at0074] occurrences matches {0..1} matches { -- Edge value matches { DV_TEXT matches {*} } } } } allow_archetype CLUSTER[at0004] occurrences matches {0..*} matches { -- Examination findings include archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches { -- Multimedia representation include archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0006] occurrences matches {0..*} matches { -- Clinical interpretation value matches { DV_TEXT matches {*} } } ELEMENT[at0007] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Examination not done include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/} } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Examination of tympanic membrane"> description = <"Findings observed during the physical examination of the tympanic membrane ."> > ["at0001"] = < text = <"Ear examined"> description = <"Identification of the ear under examination."> comment = <"This data element may be redundant if the ear examined has been specified in the archetype in which this archetype is nested."> > ["at0002"] = < text = <"No abnormality detected"> description = <"Statement that no abnormality was detected (NAD) on physical examination."> comment = <"Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element."> > ["at0003"] = < text = <"Clinical description"> description = <"Narrative description of the overall findings observed during the physical examination of the tympanic membrane."> > ["at0004"] = < text = <"Examination findings"> description = <"Structured details about the physical examination findings."> > ["at0005"] = < text = <"Multimedia representation"> description = <"Digital image, video or diagram representing the physical examination findings."> > ["at0006"] = < text = <"Clinical interpretation"> description = <"Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings."> > ["at0007"] = < text = <"Comment"> description = <"Additional narrative about the physical examination findings, not captured in other fields."> > ["at0008"] = < text = <"Examination not done"> description = <"Details to explicitly record that this examination was not performed."> > ["at0009"] = < text = <"Left"> description = <"The left ear was examined."> > ["at0010"] = < text = <"Right"> description = <"The right ear was examined."> > ["at0011"] = < text = <"View"> description = <"Description about the examiner's view of the tympanic membrane."> > ["at0012"] = < text = <"Adequate"> description = <"The tympanic membrane was clearly visualised and the duration of time was sufficient; the clinical opinion of the state of the tympanic membrane is based on adequate information."> > ["at0013"] = < text = <"Compromised"> description = <"The tympanic membrane was not clearly visualised and/or the duration of view was limited; the clinical opinion of the state of the tympanic membrane is based on limited information."> > ["at0014"] = < text = <"Total occlusion"> description = <"The tympanic membrane was not visualised; a clinical opinion of the state of the tympanic membrane could not be formed."> > ["at0015"] = < text = <"Reason for occlusion"> description = <"Narrative description of the reason for occlusion of view of the tympanic membrane."> > ["at0016"] = < text = <"Ventilation tube present?"> description = <"Is a ventilation tube observed in the tympanic membrane?"> > ["at0017"] = < text = <"Present"> description = <"A ventilation tube is observed in the tympanic membrane or ear canal."> > ["at0018"] = < text = <"Absent"> description = <"A ventilation tube is not observed in the tympanic membrane or ear canal."> > ["at0019"] = < text = <"Ventilation tube position"> description = <"Observed position of the ventilation tube (or grommet) in the tympanic membrane or the auditory canal."> > ["at0020"] = < text = <"In situ"> description = <"The ventilation tube is located in situ in the tympanic membrane."> > ["at0021"] = < text = <"Partially extruded"> description = <"The ventilation tube is partially extruded from it's original position in the tympanic membrane."> > ["at0022"] = < text = <"Extruded - remains in canal"> description = <"The ventilation tube has been extruded from the tympanic membrane but is visualised within the external auditory canal."> > ["at0023"] = < text = <"Membrane intact?"> description = <"Is the tympanic membrane intact?"> > ["at0024"] = < text = <"Intact"> description = <"The tympanic membrane appears intact."> > ["at0025"] = < text = <"Perforated"> description = <"A perforation is observed in the tympanic membrane."> > ["at0026"] = < text = <"Indeterminate"> description = <"It is not possible to determine if the tympanic membrane is intact or perforated."> > ["at0027"] = < text = <"Appearance"> description = <"Category describing the appearance of the tympanic membrane."> > ["at0028"] = < text = <"Translucent"> description = <"The tympanic membrane appears translucent and healthy."> > ["at0029"] = < text = <"Opaque"> description = <"The tympanic membrane appears dull and opaque."> > ["at0030"] = < text = <"Colour"> description = <"Description of the overall colour of the tympanic membrane."> > ["at0031"] = < text = <"Light reflex"> description = <"Is a normal light reflex observed?"> > ["at0032"] = < text = <"Normal"> description = <"A normal light reflex is observed."> > ["at0033"] = < text = <"Abnormal"> description = <"A normal light reflex is not observed."> > ["at0034"] = < text = <"Surface features"> description = <"Features observed on the surface of the tympanic membrane."> comment = <"This data element has multiple occurrences to enable multiple selections, if required. In most situations, this data element would only be recorded if the tympanic membrane is intact."> > ["at0035"] = < text = <"Location of tympanosclerosis"> description = <"Description of the location of any tympanosclerosis observed on the tympanic membrane."> > ["at0036"] = < text = <"Position of tympanic membrane"> description = <"Description of the position of the tympanic membrane."> > ["at0037"] = < text = <"Neutral"> description = <"The tympanic membrane is in a normal, neutral position - neither bulging or retracted."> > ["at0038"] = < text = <"Retracted"> description = <"The tympanic membrane appears to be retracted."> > ["at0039"] = < text = <"Bulging"> description = <"The tympanic membrane appears to be bulging."> > ["at0040"] = < text = <"Indeterminate"> description = <"The position of the tympanic membrane is is not able to be determined."> > ["at0041"] = < text = <"Retraction description"> description = <"Narrative description of the retraction of the tympanic membrane."> > ["at0042"] = < text = <"Retraction grade"> description = <"Description of retraction using formal classification."> > ["at0043"] = < text = <"Fluid level presence"> description = <"Observation of a fluid level behind the tympanic membrane."> > ["at0044"] = < text = <"Present"> description = <"A fluid level is observed behind the tympanic membrane."> > ["at0045"] = < text = <"Absent"> description = <"A fluid level is not observed behind the tympanic membrane."> > ["at0046"] = < text = <"Fluid level description"> description = <"Narrative description of the fluid level and other related features observed behind the tympanic membrane."> > ["at0047"] = < text = <"Mobility"> description = <"Description of mobility of the tympanic membrane."> comment = <"Occurrences has been set to 0..* to enable multiple methods of observing mobility to be recorded. For example: 'Mobility (Pneumatic Otoscopy'; or 'Mobility (Valsalva) with Mobile or Indeterminate as only appropriate value set."> > ["at0048"] = < text = <"Immobile"> description = <"Minimal or no movement of the tympanic membrane is observed when positive pressure is applied."> > ["at0049"] = < text = <"Hypomobile"> description = <"Less than 1mm inward (medial) movement of the tympanic membrane is observed when positive pressure is applied. The movement may be sluggish."> > ["at0050"] = < text = <"Mobile"> description = <"Crisp, inward (medial) movement (approx 1mm) when positive pressure is applied."> > ["at0051"] = < text = <"Hypermobile"> description = <"Exaggerated movement of the tympanic membrane is observed when positive pressure is applied."> > ["at0052"] = < text = <"Indeterminate"> description = <"It is not possible to determine the amount of movement of the tympanic membrane."> > ["at0053"] = < text = <"Perforation details"> description = <"Details about a perforation in the tympanic membrane."> > ["at0054"] = < text = <"Perforation description"> description = <"Narrative description of the perforation of the tympanic membrane."> > ["at0055"] = < text = <"Estimation of size"> description = <"Estimation of the size of the tympanic membrane perforation, based on anatomical landmarks."> > ["at0056"] = < text = <"Pinhole"> description = <"The perforation is the size of a pinhole."> > ["at0057"] = < text = <"Intermediate"> description = <"The perforation is larger than a pinhole but smaller than a subtotal perforation."> > ["at0058"] = < text = <"Subtotal"> description = <"The perforation is subtotal: the pars tensa is absent but the perforation does not include the annulus."> > ["at0059"] = < text = <"Total"> description = <"The tympanic membrane is essentially absent."> > ["at0060"] = < text = <"Intermediate estimation"> description = <"Further detail about the size of an intermediate perforation."> > ["at0061"] = < text = <"<40%"> description = <"The intermediate perforation is less than 40% of the area of the tympanic membrane."> > ["at0062"] = < text = <">40%"> description = <"The intermediate perforation is greater than 40% of the area of the tympanic membrane."> > ["at0063"] = < text = <"Measurement"> description = <"Direct measurement of the size of the tympanic membrane perforation, usually using a photograph as the source for direct measurement."> > ["at0064"] = < text = <"Ventilation tube description"> description = <"Narrative description about the appearance of the ventilation tubes."> > ["at0065"] = < text = <"Pars flaccida vs pars tensa?"> description = <"Description of the region of the tympanic membrane perforation."> comment = <"To document explicitly whether the perforation is located in the Pars flaccida and may be potentially unsafe. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant. Coding with a terminology is preferred, if possible."> > ["at0066"] = < text = <"Pars flaccida"> description = <"The perforation is located in the pars flaccida."> > ["at0067"] = < text = <"Pars tensa"> description = <"The tympanic membrane perforation is located in the pars tensa."> > ["at0068"] = < text = <"Marginal vs central?"> description = <"Location of the tympanic membrane perforation."> comment = <"To document explicitly whether the perforation is located marginally, and therefore might be clinically unsafe. If 'Total' is selected in 'Estimation of Size' data element then this data element becomes redundant."> > ["at0069"] = < text = <"Marginal"> description = <"The perforation involves the annulus of the tympanic membrane."> > ["at0070"] = < text = <"Central"> description = <"The perforation is not involving the annulus and is bounded on all sides by the remnant of the tympanic membrane."> > ["at0071"] = < text = <"Anterior?"> description = <"Is an anterior perforation present?"> comment = <"To document the presence of perforation in the anterior portions of the pars tensa, whcih can be more difficult to manage than perforations elsewhere. If 'Total' or 'Subtotal' is selected in 'Estimation of Size' data element then this data element becomes redundant."> > ["at0072"] = < text = <"Present"> description = <"An anterior perforation is present in the pars tensa."> > ["at0073"] = < text = <"Absent"> description = <"An anterior perforation is not present in the pars tensa."> > ["at0074"] = < text = <"Edge"> description = <"Narrative description of the edge of the perforation."> > > > >