archetype (adl_version=1.4) openEHR-EHR-CLUSTER.exam-ears.v1 specialise openEHR-EHR-CLUSTER.exam.v1 concept [at0000.1] -- Examination of the ears language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Ian McNicoll"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"ian.mcnicoll@oceaninformatics.com"> ["date"] = <"02/11/2007"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording findings on physical examination of the ears."> use = <""> keywords = <"examination", "physical", "ears", "ENT", "tympanic", "mastoid", "Rinne", "Weber"> misuse = <"Do not use for recording audiology findings Should normally be contained within an OBSERVATION"> copyright = <"copyright (c) 2010 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["MD5-CAM-1.0.1"] = <"4C3FA1F70C90356DC3CA61F87EDAD866"> ["references"] = <""> > definition CLUSTER[at0000.1] matches { -- Examination of the ears items cardinality matches {1..*; unordered} matches { CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements items cardinality matches {1..*; unordered} matches { ELEMENT[at0005] occurrences matches {0..1} matches { -- Normal statement value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.48, -- Both ears normal at0.49, -- Left ear normal at0.50] -- Right ear normal } } } } } } ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } CLUSTER[at0.66] occurrences matches {0..2} matches { -- Lateral Findings items cardinality matches {1..*; unordered} matches { ELEMENT[at0.16] occurrences matches {0..1} matches { -- Side value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.17, -- Left at0.18] -- Right } } } } CLUSTER[at0.57] occurrences matches {0..1} matches { -- Physical items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER[at0.76] occurrences matches {0..1} matches { -- External ear detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.palpation-external_ear(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.inspection-external_ear(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype CLUSTER[at0.77] occurrences matches {0..*} matches { -- Auditory canal detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.inspection-ear_canal(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype CLUSTER[at0.75] occurrences matches {0..1} matches { -- Tympanic membrane detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.inspection-tympanic_perforation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.inspection-tympanic_membrane(-[a-zA-Z0-9_]+)*\.v1/} } } } CLUSTER[at0.56] occurrences matches {0..1} matches { -- Functional items cardinality matches {1..*; unordered} matches { ELEMENT[at0.24] occurrences matches {0..1} matches { -- Whisper test value matches { DV_TEXT matches {*} } } ELEMENT[at0.68] occurrences matches {0..1} matches { -- Rinne Test value matches { 0|[local::at0.69], -- Negative 1|[local::at0.70]; -- Positive 0 -- assumed value } } } } allow_archetype CLUSTER[at0009] occurrences matches {0..*} matches { -- Detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam-generic(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.auscultation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.inspection(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.palpation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.percussion(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0006] occurrences matches {0..*} matches { -- Image value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 426, 427, 429] } } } } } } CLUSTER[at0008.1] occurrences matches {0..1} matches { -- Central findings items cardinality matches {1..*; unordered} matches { CLUSTER[at0.67] occurrences matches {0..1} matches { -- Functional items cardinality matches {1..*; unordered} matches { ELEMENT[at0.71] occurrences matches {0..1} matches { -- Weber Test value matches { 0|[local::at0.72], -- Normal 1|[local::at0.73], -- Lateralising Left 2|[local::at0.74]; -- Lateralising Right 0 -- assumed value } } allow_archetype CLUSTER[at0.78] occurrences matches {0..*} matches { -- Detail include archetype_id/value matches {/.*/} } } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0.16"] = < text = <"Side"> description = <"Left or Right ear examined?"> > ["at0.17"] = < text = <"Left"> description = <"Left ear."> > ["at0.18"] = < text = <"Right"> description = <"Right ear."> > ["at0.24"] = < text = <"Whisper test"> description = <"A simple hearing test."> > ["at0.48"] = < text = <"Both ears normal"> description = <"Both ears are normal."> > ["at0.49"] = < text = <"Left ear normal"> description = <"The left ear is normal."> > ["at0.50"] = < text = <"Right ear normal"> description = <"The right ear is normal."> > ["at0.56"] = < text = <"Functional"> description = <"Lateral tests of ear function."> > ["at0.57"] = < text = <"Physical"> description = <"Physical examination of the ear."> > ["at0.66"] = < text = <"Lateral Findings"> description = <"Clinical findings related to a single ear."> > ["at0.67"] = < text = <"Functional"> description = <"Central functional auditory tests."> > ["at0.68"] = < text = <"Rinne Test"> description = <"A test to compare bone and air conduction of sound."> > ["at0.69"] = < text = <"Negative"> description = <"The Rinne test is positive."> > ["at0.70"] = < text = <"Positive"> description = <"The Rinne test is negative."> > ["at0.71"] = < text = <"Weber Test"> description = <"A test to distinguish conductive and sensoineural hearing loss."> > ["at0.72"] = < text = <"Normal"> description = <"The Weber test is not lateralised - normal."> > ["at0.73"] = < text = <"Lateralising Left"> description = <"The result of the Weber test is lateralising to the left."> > ["at0.74"] = < text = <"Lateralising Right"> description = <"The result of the Weber test is lateralising to the right."> > ["at0.75"] = < text = <"Tympanic membrane detail"> description = <"Detailed findings related to the tmpanic membrane or perforation."> > ["at0.76"] = < text = <"External ear detail"> description = <"Detailed findings related to the external ear."> > ["at0.77"] = < text = <"Auditory canal detail"> description = <"Detailed findings related to the audiory canal."> > ["at0.78"] = < text = <"Detail"> description = <"Further detailed functional findings."> > ["at0000"] = < text = <"Examination"> description = <"Basic examination cluster for describing findings on physical examination when there is no named focus of examination."> > ["at0000.1"] = < text = <"Examination of the ears"> description = <"Examination cluster for describing findings on physical examination of the eyes."> > ["at0002"] = < text = <"Clinical description"> description = <"Textural description of the part examined."> > ["at0004"] = < text = <"Normal statements"> description = <"A group of statements about the normality of the examination."> > ["at0005"] = < text = <"Normal statement"> description = <"A specific statement of normality."> > ["at0006"] = < text = <"Image"> description = <"Drawing or image of the area examined."> > ["at0008"] = < text = <"Lateral Findings"> description = <"Clinical findings related to a single ear."> > ["at0008.1"] = < text = <"Central findings"> description = <"Clinical findings related to both ears."> > ["at0009"] = < text = <"Detail"> description = <"More focused examination findings."> > > > >