archetype (adl_version=1.4) openEHR-EHR-CLUSTER.exam_middle_ear.v1 concept [at0000] -- Examination of Middle Ear language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"2013-03-20"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record examination findings of the middle ear, usually at operation."> use = <"Use to record examination findings of the middle ear, usually at operation."> keywords = <"operation", "myringoplasty"> misuse = <""> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"CommitteeDraft"> other_contributors = <> other_details = < ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> ["references"] = <"NT Health, Hearing Health Program, \"ENT Pre Op Exam & Surgical Procedure Form\""> ["MD5-CAM-1.0.1"] = <"9728D9AA424EFF5D04644C42CC88D121"> > definition CLUSTER[at0000] matches { -- Examination of Middle Ear 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:: at0002, -- Left at0003] -- Right } } } } ELEMENT[at0012] occurrences matches {0..1} matches { -- No Abnormality Detected value matches { DV_BOOLEAN matches { value matches {True} } } } ELEMENT[at0004] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0005] occurrences matches {0..1} matches { -- Ossicular Chain State value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0006, -- Intact at0007] -- Not Intact } } } } ELEMENT[at0008] occurrences matches {0..1} matches { -- Ossicular Chain Mobility value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0009, -- Mobile at0010] -- Immobile } } } } ELEMENT[at0011] occurrences matches {0..1} matches { -- Clinical Interpretation value matches { DV_TEXT matches {*} } } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Examination of Middle Ear"> description = <"Examination of the middle ear, usually at operation."> > ["at0001"] = < text = <"Ear Examined"> description = <"Identification of the ear under examination."> > ["at0002"] = < text = <"Left"> description = <"The left middle ear."> > ["at0003"] = < text = <"Right"> description = <"The right middle ear."> > ["at0004"] = < text = <"Description"> description = <"Narrative description of findings observed during examination of the middle ear."> > ["at0005"] = < text = <"Ossicular Chain State"> description = <"Description of status of the ossicular chain."> > ["at0006"] = < text = <"Intact"> description = <"Ossicular chain is intact."> > ["at0007"] = < text = <"Not Intact"> description = <"Ossicular chain is not intact."> > ["at0008"] = < text = <"Ossicular Chain Mobility"> description = <"Description of the mobility of the ossicular chain."> > ["at0009"] = < text = <"Mobile"> description = <"Ossicular chain is mobile."> > ["at0010"] = < text = <"Immobile"> description = <"Ossicular chain is not mobile."> > ["at0011"] = < text = <"Clinical Interpretation"> description = <"Single word, phrase or brief description representing a summary of the examination findings."> > ["at0012"] = < text = <"No Abnormality Detected"> description = <"Statement that no abnormality was detected on examination of the middle ear."> 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."> > > > >