archetype (adl_version=1.4) openEHR-EHR-CLUSTER.palpation.v1 concept [at0000] -- Palpation language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"unknown"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record data found on examination through palpation."> use = <"To be embedded in the openEHR-EHR-OBSERVATION.exam cluster to express findings determined by palpation."> keywords = <"palpate", ...> misuse = <"Not for use in any other context at present."> copyright = <"copyright (c) 2010 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["MD5-CAM-1.0.1"] = <"6997D54D3789258C693D939FAFFB0CEE"> ["references"] = <""> > definition CLUSTER[at0000] matches { -- Palpation items cardinality matches {1..*; unordered} matches { CLUSTER[at0059] occurrences matches {0..1} matches { -- Normal statements items cardinality matches {1..*; unordered} matches { ELEMENT[at0012] occurrences matches {0..*} matches { -- Normal statement value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0013, -- Normal at0014, -- Probably normal at0015, -- No abnormality detected at0060, -- Soft at0061, -- No tenderness at0068, -- No masses at0069, -- No foreign bodies at0082] -- No hernias } } } } } } ELEMENT[at0001] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } CLUSTER[at0080] occurrences matches {0..1} matches { -- Findings items cardinality matches {1..*; unordered} matches { CLUSTER[at0019] occurrences matches {0..*} matches { -- Tenderness items cardinality matches {1..*; unordered} matches { ELEMENT[at0002] occurrences matches {0..1} matches { -- Depth of palpation value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0003, -- Superficial at0004] -- Deep } } } } ELEMENT[at0020] occurrences matches {0..1} matches { -- Degree value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0006, -- absent at0021, -- mild at0022, -- moderate at0023, -- marked at0024] -- extreme } } } } ELEMENT[at0005] occurrences matches {0..1} matches { -- Category value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0007, -- Superficial tenderness at0008, -- Deep tenderness at0009, -- Rebound tenderness at0019, -- Tenderness at0025] -- Rigidity } } } } use_node ELEMENT /items[at0080]/items[at0010]/items[at0011] -- /items[Findings]/items[Localised palpation]/items[Body site] } } ELEMENT[at0041] occurrences matches {0..1} matches { -- Temperature value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0042, -- Cold at0043, -- Cool at0044, -- Normal at0045, -- Warm at0046] -- Hot } } } } CLUSTER[at0070] occurrences matches {0..1} matches { -- Guarding items cardinality matches {1..*; unordered} matches { ELEMENT[at0071] occurrences matches {0..1} matches { -- Degree value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0076, -- Not present at0077, -- Mild at0078, -- Moderate at0079] -- Gross } } } } ELEMENT[at0072] occurrences matches {0..1} matches { -- Nature value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0073, -- Voluntary at0074, -- Involuntary at0075] -- Uncertain } } } } } } CLUSTER[at0010] occurrences matches {0..*} matches { -- Localised palpation items cardinality matches {1..*; unordered} matches { ELEMENT[at0011] matches { -- Body site value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0083] occurrences matches {0..2} matches { -- Cluster: Localised palpation include archetype_id/value matches {/openEHR-EHR-CLUSTER\.palpation\.v1/} } ELEMENT[at0081] occurrences matches {0..1} matches { -- Cough impulse value matches { DV_BOOLEAN matches { value matches {True} } } } } } CLUSTER[at0053] occurrences matches {0..1} matches { -- Surface/Border name matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0064, -- Surface at0065] -- Edge } } } items cardinality matches {1..*; unordered} matches { ELEMENT[at0067] occurrences matches {0..1} matches { -- Site description value matches { DV_TEXT matches {*} } } ELEMENT[at0048] occurrences matches {0..1} matches { -- Consistency value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0049, -- Hard/Rigid at0050, -- Firm at0052, -- Soft at0062, -- Boggy at0063] -- Indents } } } } ELEMENT[at0054] occurrences matches {0..*} matches { -- Features value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0055, -- Smooth at0056, -- Craggy at0057, -- Irregular at0058] -- Nodular } } } } } } CLUSTER[at0047] occurrences matches {0..1} matches { -- Detail items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER[at0084] occurrences matches {0..1} matches { -- Cluster: Exam details include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam\.v1|openEHR-EHR-CLUSTER\.exam-mass\.v1/} exclude archetype_id/value matches {/.*/} } } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Palpation"> description = <"Findings on palpation."> > ["at0001"] = < text = <"Clinical description"> description = <"Textural statement of the findings on palpation."> > ["at0002"] = < text = <"Depth of palpation"> description = <"The depth of palpation."> > ["at0003"] = < text = <"Superficial"> description = <"Superficial palpation of the skin and superficial muscles."> > ["at0004"] = < text = <"Deep"> description = <"Palpation of the deep structures beneath superficial muscles."> > ["at0005"] = < text = <"Category"> description = <"The type of tenderness found on palpation."> > ["at0006"] = < text = <"absent"> description = <"No tenderness on palpation."> > ["at0007"] = < text = <"Superficial tenderness"> description = <"Tender in the superficial layers."> > ["at0008"] = < text = <"Deep tenderness"> description = <"Tenderness in the deep structures."> > ["at0009"] = < text = <"Rebound tenderness"> description = <"Tenderness on releasing palpation pressure."> > ["at0010"] = < text = <"Localised palpation"> description = <"Palpation of a localised area."> > ["at0011"] = < text = <"Body site"> description = <"The region, site or organ that is the object of localised palpation."> > ["at0012"] = < text = <"Normal statement"> description = <"A specific statement of normality."> > ["at0013"] = < text = <"Normal"> description = <"The palpation is normal."> > ["at0014"] = < text = <"Probably normal"> description = <"The palpation is apparently normal but some uncertainty exists."> > ["at0015"] = < text = <"No abnormality detected"> description = <"No abnormality was detected by palpation."> > ["at0019"] = < text = <"Tenderness"> description = <"A group of statements about a tenderness finding."> > ["at0020"] = < text = <"Degree"> description = <"The amount or degree of tenderness found on palpation."> > ["at0021"] = < text = <"mild"> description = <"There is some feeling of pain or discomfort on palpation."> > ["at0022"] = < text = <"moderate"> description = <"There is definite pain on palpation."> > ["at0023"] = < text = <"marked"> description = <"Gentle palpation leads to moderate pain."> > ["at0024"] = < text = <"extreme"> description = <"Gentle palpation leads to severe pain."> > ["at0025"] = < text = <"Rigidity"> description = <"The abdomen is rigid to palpation."> > ["at0041"] = < text = <"Temperature"> description = <"The temperature on palpation."> > ["at0042"] = < text = <"Cold"> description = <"The feeling of cold."> > ["at0043"] = < text = <"Cool"> description = <"The temperature feels cooler than normal."> > ["at0044"] = < text = <"Normal"> description = <"The temperature feels normal."> > ["at0045"] = < text = <"Warm"> description = <"The temperature feels warmer than normal."> > ["at0046"] = < text = <"Hot"> description = <"The temperature feels hot."> > ["at0047"] = < text = <"Detail"> description = <"Detailed examination of things found on palpation."> > ["at0048"] = < text = <"Consistency"> description = <"The consistency of the surface or border of the object of palpation."> > ["at0049"] = < text = <"Hard/Rigid"> description = <"The surface is hard or rigid."> > ["at0050"] = < text = <"Firm"> description = <"The surface is firm."> > ["at0052"] = < text = <"Soft"> description = <"The surface is soft."> > ["at0053"] = < text = <"Surface/Border"> description = <"Findings related to the surface or border of the object of palpation."> > ["at0054"] = < text = <"Features"> description = <"Features of the surface or border."> > ["at0055"] = < text = <"Smooth"> description = <"The surface or border is smooth."> > ["at0056"] = < text = <"Craggy"> description = <"Large irregularities."> > ["at0057"] = < text = <"Irregular"> description = <"The surface or border is irregular."> > ["at0058"] = < text = <"Nodular"> description = <"The surface contains nodules."> > ["at0059"] = < text = <"Normal statements"> description = <"A group of statements about the normality of the palpation."> > ["at0060"] = < text = <"Soft"> description = <"The palpation revealed no distension, masses or rigidity."> > ["at0061"] = < text = <"No tenderness"> description = <"Palpation revealed no tenderness."> > ["at0062"] = < text = <"Boggy"> description = <"The surface is soft with a boggy quality."> > ["at0063"] = < text = <"Indents"> description = <"The border or surface retains indentation after firm pressure is applied."> > ["at0064"] = < text = <"Surface"> description = <"The surface of the object of palpation."> > ["at0065"] = < text = <"Edge"> description = <"The border of the object of palpation."> > ["at0067"] = < text = <"Site description"> description = <"Details of the location of the surface or border palpated."> > ["at0068"] = < text = <"No masses"> description = <"No masses palpable."> > ["at0069"] = < text = <"No foreign bodies"> description = <"No foreign bodies are palpable."> > ["at0070"] = < text = <"Guarding"> description = <"Tensing of underlying muscles on palpation."> > ["at0071"] = < text = <"Degree"> description = <"The degree of guarding."> > ["at0072"] = < text = <"Nature"> description = <"The nature of the guarding."> > ["at0073"] = < text = <"Voluntary"> description = <"The guarding is apparently deliberate on the part of the person."> > ["at0074"] = < text = <"Involuntary"> description = <"The guarding is occuring without intent from the person."> > ["at0075"] = < text = <"Uncertain"> description = <"The guarding is not clearly involuntary or voluntary."> > ["at0076"] = < text = <"Not present"> description = <"Guarding is not present."> > ["at0077"] = < text = <"Mild"> description = <"There is some guarding with deep palpation."> > ["at0078"] = < text = <"Moderate"> description = <"There is guarding on moderate palpation."> > ["at0079"] = < text = <"Gross"> description = <"There is guarding on very gentle palpation."> > ["at0080"] = < text = <"Findings"> description = <"Group of findings."> > ["at0081"] = < text = <"Cough impulse"> description = <"Presence of a cough impulse felt on palpation."> > ["at0082"] = < text = <"No hernias"> description = <"Palpation revealed no hernias."> > ["at0083"] = < text = <"Cluster: Localised palpation"> description = <"Palpation"> > ["at0084"] = < text = <"Cluster: Exam details"> description = <"Exam details"> > > > >