archetype (adl_version=1.4) openEHR-EHR-CLUSTER.inspection-skin-wound.v1 specialise openEHR-EHR-CLUSTER.inspection-skin.v1 concept [at0000.1.1] -- Inspection of open wound language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"10/04/2007"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording the findings on inspection of a wound"> use = <"For use with the exam clusters for recording findings on inspection"> keywords = <"inspect", "visual", "skin", "wound"> misuse = <"Should only be used in the exam observation"> copyright = <"copyright (c) 2009 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <> other_details = < ["references"] = <""> > definition CLUSTER[at0000.1.1] matches { -- Inspection of open wound items cardinality matches {0..*; unordered} matches { CLUSTER[at0001] occurrences matches {0..1} matches { -- Normal statements items cardinality matches {0..*; unordered} matches { ELEMENT[at0002] occurrences matches {0..*} matches { -- Normal statement value matches { DV_TEXT matches {*} } } } } ELEMENT[at0048] occurrences matches {0..1} matches { -- Clinical Description value matches { DV_TEXT matches {*} } } CLUSTER[at0006] occurrences matches {0..*} matches { -- Findings items cardinality matches {0..*; unordered} matches { ELEMENT[at0.0.70] occurrences matches {0..1} matches { -- Type value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.0.71, -- Abrasion (graze) at0.0.72, -- Laceration at0.0.73, -- Incision at0.0.74, -- Puncture wound at0.0.75, -- Penetration wound at0.0.76] -- Gunshot wound } } } } CLUSTER[at0005] occurrences matches {0..1} matches { -- Location items cardinality matches {0..*; unordered} matches { ELEMENT[at0022] occurrences matches {0..*} matches { -- Description value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } } } CLUSTER[at0.0.79] occurrences matches {0..1} matches { -- Extent items cardinality matches {0..*; unordered} matches { ELEMENT[at0.0.80] occurrences matches {0..1} matches { -- Starting point value matches { DV_TEXT matches {*} } } ELEMENT[at0.0.81] occurrences matches {0..1} matches { -- End point value matches { DV_TEXT matches {*} } } ELEMENT[at0.0.82] occurrences matches {0..1} matches { -- Course value matches { DV_TEXT matches {*} } } } } ELEMENT[at0036] occurrences matches {0..1} matches { -- Colour description value matches { DV_TEXT matches {*} } } CLUSTER[at0.0.83] occurrences matches {0..1} matches { -- Depth items cardinality matches {0..*; unordered} matches { ELEMENT[at0.0.84] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } CLUSTER[at0.0.85] occurrences matches {0..1} matches { -- Tissue involvement items cardinality matches {0..*; unordered} matches { ELEMENT[at0.0.86] occurrences matches {0..1} matches { -- Ligament value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.87] occurrences matches {0..1} matches { -- Muscle value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.88] occurrences matches {0..1} matches { -- Bone value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.89] occurrences matches {0..1} matches { -- Joint value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.90] occurrences matches {0..1} matches { -- Subcutaneous fat value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.91] occurrences matches {0..1} matches { -- Skin only value matches { DV_BOOLEAN matches { value matches {True, False} } } } } } } } CLUSTER[at0018] occurrences matches {0..1} matches { -- Shape or distribution items cardinality matches {0..*; unordered} matches { ELEMENT[at0019] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0020] occurrences matches {0..1} matches { -- Symmetrical value matches { DV_BOOLEAN matches { value matches {True, False} } } } } } ELEMENT[at0.0.62] occurrences matches {0..1} matches { -- Age value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.0.63, -- Acute at0.0.64] -- Chronic } } } } CLUSTER[at0.0.65] occurrences matches {0..1} matches { -- Signs of infection items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0.0.130] occurrences matches {0..1} matches { include archetype_id/value matches {/openEHR-EHR-CLUSTER\.signs_of_infection\.v1/} exclude archetype_id/value matches {/.*/} } } } CLUSTER[at0.0.61] occurrences matches {0..1} matches { -- Size items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0.0.131] occurrences matches {0..1} matches { include archetype_id/value matches {/openEHR-EHR-CLUSTER\.size\.v1|openEHR-EHR-CLUSTER\.dimensions\.v1|openEHR-EHR-CLUSTER\.dimensions-circumference\.v1/} } } } ELEMENT[at0051] occurrences matches {0..1} matches { -- Contour value matches { DV_TEXT matches {*} } } CLUSTER[at0.0.92] occurrences matches {0..1} matches { -- Wound bed items cardinality matches {0..*; unordered} matches { ELEMENT[at0027] occurrences matches {0..1} matches { -- Surface value matches { DV_TEXT matches {*} } } ELEMENT[at0.0.93] occurrences matches {0..1} matches { -- Eschar present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.94] occurrences matches {0..1} matches { -- Necrotic tissue value matches { 0|[local::at0.0.100], -- - 1|[local::at0.0.101], -- + 2|[local::at0.0.102], -- ++ 3|[local::at0.0.103]; -- +++ 0 -- assumed value } } ELEMENT[at0.0.95] occurrences matches {0..1} matches { -- Slough value matches { 0|[local::at0.0.96], -- - 1|[local::at0.0.97], -- + 2|[local::at0.0.98], -- ++ 3|[local::at0.0.99]; -- +++ 0 -- assumed value } } ELEMENT[at0.0.104] occurrences matches {0..1} matches { -- Granulation tissue value matches { DV_TEXT matches {*} } } ELEMENT[at0.0.105] occurrences matches {0..1} matches { -- Overgranulation value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.106] occurrences matches {0..1} matches { -- Epithelialisation value matches { DV_BOOLEAN matches { value matches {True, False} } } } } } ELEMENT[at0.56] occurrences matches {0..1} matches { -- Thickness value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.57, -- Thickened at0.58, -- Normal at0.59] -- Thinned/Atrophic } } } } CLUSTER[at0.0.107] occurrences matches {0..1} matches { -- Surrounds items cardinality matches {0..*; unordered} matches { ELEMENT[at0.0.108] occurrences matches {0..1} matches { -- Normal/Healthy value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0024] occurrences matches {0..1} matches { -- Surrounds value matches { DV_TEXT matches {*} } } CLUSTER[at0.0.109] occurrences matches {0..1} matches { -- Induration items cardinality matches {0..*; unordered} matches { ELEMENT[at0.0.110] occurrences matches {0..1} matches { -- Present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.111] occurrences matches {0..1} matches { -- Description value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } } } ELEMENT[at0.0.112] occurrences matches {0..1} matches { -- Callus present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.113] occurrences matches {0..1} matches { -- Maceration present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.114] occurrences matches {0..1} matches { -- Eczema present value matches { DV_BOOLEAN matches { value matches {True, False} } } } CLUSTER[at0.0.115] occurrences matches {0..1} matches { -- Blisters items cardinality matches {0..*; unordered} matches { use_node ELEMENT /items[at0006]/items[at0.0.107]/items[at0.0.109]/items[at0.0.110] -- /items[Findings]/items[Surrounds]/items[Induration]/items[Present] use_node ELEMENT /items[at0006]/items[at0.0.107]/items[at0.0.109]/items[at0.0.111] -- /items[Findings]/items[Surrounds]/items[Induration]/items[Description] } } ELEMENT[at0.0.117] occurrences matches {0..1} matches { -- Fragile skin present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.116] occurrences matches {0..1} matches { -- Dry skin present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.118] occurrences matches {0..1} matches { -- Erythema present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.119] occurrences matches {0..1} matches { -- Cellulitis present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.120] occurrences matches {0..1} matches { -- Oedema present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.121] occurrences matches {0..1} matches { -- Fistula or sinus present value matches { DV_BOOLEAN matches { value matches {True, False} } } } } } ELEMENT[at0.60] occurrences matches {0..1} matches { -- Pigmentation value matches { DV_TEXT matches {*} } } ELEMENT[at0.0.69] occurrences matches {0..1} matches { -- Contamination value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } ELEMENT[at0.0.122] occurrences matches {0..1} matches { -- Odour value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.0.123, -- None at0.0.124] -- Malodourous } } } } CLUSTER[at0.0.66] occurrences matches {0..1} matches { -- Foreign body items cardinality matches {0..*; unordered} matches { ELEMENT[at0.0.67] occurrences matches {0..1} matches { -- Present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.0.68] occurrences matches {0..1} matches { -- Details value matches { DV_TEXT matches {*} } } } } CLUSTER[at0.0.125] occurrences matches {0..1} matches { -- Discharge items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0.0.132] occurrences matches {0..1} matches { include archetype_id/value matches {/openEHR-EHR-CLUSTER\.fluid\.v1/} exclude archetype_id/value matches {/.*/} } } } CLUSTER[at0028] occurrences matches {0..1} matches { -- Edge items cardinality matches {0..*; unordered} matches { ELEMENT[at0033] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } ELEMENT[at0029] occurrences matches {0..1} matches { -- Definition value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0030, -- Well defined at0031, -- Moderately defined at0032] -- Poorly defined } } } } ELEMENT[at0.0.126] occurrences matches {0..1} matches { -- Slope value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.0.127, -- Punched out at0.0.128, -- Undermined at0.0.129] -- Everted } } } } } } ELEMENT[at0034] occurrences matches {0..1} matches { -- Translucent value matches { DV_BOOLEAN matches { value matches {True, False} } } } CLUSTER[at0049] occurrences matches {0..1} matches { -- Detail items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0052] occurrences matches {0..1} matches { include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam\.v1/} } } } ELEMENT[at0.52] occurrences matches {0..1} matches { -- Method value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.53, -- Direct visualisation at0.54, -- Wood's lamp at0.55] -- Dermatoscope } } } } } } ELEMENT[at0050] occurrences matches {0..1} matches { -- Drawing value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 425, 426, 427, 428, 429] } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0.0.100"] = < text = <"-"> description = <"Absent"> > ["at0.0.101"] = < text = <"+"> description = <"Minimal"> > ["at0.0.102"] = < text = <"++"> description = <"Moderate"> > ["at0.0.103"] = < text = <"+++"> description = <"Excessive"> > ["at0.0.104"] = < text = <"Granulation tissue"> description = <"*"> > ["at0.0.105"] = < text = <"Overgranulation"> description = <"*"> > ["at0.0.106"] = < text = <"Epithelialisation"> description = <"*"> > ["at0.0.107"] = < text = <"Surrounds"> description = <"*"> > ["at0.0.108"] = < text = <"Normal/Healthy"> description = <"*"> > ["at0.0.109"] = < text = <"Induration"> description = <"*"> > ["at0.0.110"] = < text = <"Present"> description = <"*"> > ["at0.0.111"] = < text = <"Description"> description = <"*"> > ["at0.0.112"] = < text = <"Callus present"> description = <"*"> > ["at0.0.113"] = < text = <"Maceration present"> description = <"*"> > ["at0.0.114"] = < text = <"Eczema present"> description = <"*"> > ["at0.0.115"] = < text = <"Blisters"> description = <"*"> > ["at0.0.116"] = < text = <"Dry skin present"> description = <"*"> > ["at0.0.117"] = < text = <"Fragile skin present"> description = <"*"> > ["at0.0.118"] = < text = <"Erythema present"> description = <"*"> > ["at0.0.119"] = < text = <"Cellulitis present"> description = <"*"> > ["at0.0.120"] = < text = <"Oedema present"> description = <"*"> > ["at0.0.121"] = < text = <"Fistula or sinus present"> description = <"*"> > ["at0.0.122"] = < text = <"Odour"> description = <"*"> > ["at0.0.123"] = < text = <"None"> description = <"*"> > ["at0.0.124"] = < text = <"Malodourous"> description = <"*"> > ["at0.0.125"] = < text = <"Discharge"> description = <"*"> > ["at0.0.126"] = < text = <"Slope"> description = <"*"> > ["at0.0.127"] = < text = <"Punched out"> description = <"Vertical edge"> > ["at0.0.128"] = < text = <"Undermined"> description = <"Slope inwards"> > ["at0.0.129"] = < text = <"Everted"> description = <"Slope outwards"> > ["at0.0.130"] = < text = <"Cluster: Signs of infection"> description = <"*"> > ["at0.0.131"] = < text = <"Cluster: Dimensions"> description = <"*"> > ["at0.0.132"] = < text = <"Cluster: Fluids"> description = <"*"> > ["at0.0.61"] = < text = <"Size"> description = <"*"> > ["at0.0.62"] = < text = <"Age"> description = <"*"> > ["at0.0.63"] = < text = <"Acute"> description = <"*"> > ["at0.0.64"] = < text = <"Chronic"> description = <"*"> > ["at0.0.65"] = < text = <"Signs of infection"> description = <"Presence of signs of infection"> > ["at0.0.66"] = < text = <"Foreign body"> description = <"*"> > ["at0.0.67"] = < text = <"Present"> description = <"*"> > ["at0.0.68"] = < text = <"Details"> description = <"*"> > ["at0.0.69"] = < text = <"Contamination"> description = <"Description about contamination of the wound"> > ["at0.0.70"] = < text = <"Type"> description = <"Type of wound"> > ["at0.0.71"] = < text = <"Abrasion (graze)"> description = <"*"> > ["at0.0.72"] = < text = <"Laceration"> description = <"*"> > ["at0.0.73"] = < text = <"Incision"> description = <"*"> > ["at0.0.74"] = < text = <"Puncture wound"> description = <"*"> > ["at0.0.75"] = < text = <"Penetration wound"> description = <"*"> > ["at0.0.76"] = < text = <"Gunshot wound"> description = <"*"> > ["at0.0.77"] = < text = <"Contusion"> description = <"(closed wound)"> > ["at0.0.78"] = < text = <"Haematoma"> description = <"(closed wound)"> > ["at0.0.79"] = < text = <"Extent"> description = <"*"> > ["at0.0.80"] = < text = <"Starting point"> description = <"*"> > ["at0.0.81"] = < text = <"End point"> description = <"*"> > ["at0.0.82"] = < text = <"Course"> description = <"*"> > ["at0.0.83"] = < text = <"Depth"> description = <"*"> > ["at0.0.84"] = < text = <"Description"> description = <"*"> > ["at0.0.85"] = < text = <"Tissue involvement"> description = <"*"> > ["at0.0.86"] = < text = <"Ligament"> description = <"*"> > ["at0.0.87"] = < text = <"Muscle"> description = <"*"> > ["at0.0.88"] = < text = <"Bone"> description = <"*"> > ["at0.0.89"] = < text = <"Joint"> description = <"*"> > ["at0.0.90"] = < text = <"Subcutaneous fat"> description = <"*"> > ["at0.0.91"] = < text = <"Skin only"> description = <"*"> > ["at0.0.92"] = < text = <"Wound bed"> description = <"*"> > ["at0.0.93"] = < text = <"Eschar present"> description = <"*"> > ["at0.0.94"] = < text = <"Necrotic tissue"> description = <"*"> > ["at0.0.95"] = < text = <"Slough"> description = <"*"> > ["at0.0.96"] = < text = <"-"> description = <"Absent"> > ["at0.0.97"] = < text = <"+"> description = <"Minimal"> > ["at0.0.98"] = < text = <"++"> description = <"Moderate"> > ["at0.0.99"] = < text = <"+++"> description = <"Excessive"> > ["at0.52"] = < text = <"Method"> description = <"Record of findings on inspection using a specific method"> > ["at0.53"] = < text = <"Direct visualisation"> description = <"Macroscopic; By eye"> > ["at0.54"] = < text = <"Wood's lamp"> description = <"*"> > ["at0.55"] = < text = <"Dermatoscope"> description = <"*"> > ["at0.56"] = < text = <"Thickness"> description = <"Thickness of skin"> > ["at0.57"] = < text = <"Thickened"> description = <"*"> > ["at0.58"] = < text = <"Normal"> description = <"*"> > ["at0.59"] = < text = <"Thinned/Atrophic"> description = <"*"> > ["at0.60"] = < text = <"Pigmentation"> description = <"Pigmentation of skin"> > ["at0000"] = < text = <"Inspection"> description = <"The findings on physical examination by inspection"> > ["at0000.1"] = < text = <"Inspection of skin"> description = <"The findings on inspection of the skin"> > ["at0000.1.1"] = < text = <"Inspection of open wound"> description = <"The findings on inspection of a wound"> > ["at0001"] = < text = <"Normal statements"> description = <"An optional group of statements about the normality of the inspection"> > ["at0002"] = < text = <"Normal statement"> description = <"A specific statement about the normality of inspection"> > ["at0005"] = < text = <"Location"> description = <"The location of any findings"> > ["at0006"] = < text = <"Findings"> description = <"Specific findings on inspection"> > ["at0018"] = < text = <"Shape or distribution"> description = <"The shape or distribution of the object inspected"> > ["at0019"] = < text = <"Description"> description = <"Description of the "> > ["at0020"] = < text = <"Symmetrical"> description = <"Whether the distribution is symmetrical"> > ["at0022"] = < text = <"Description"> description = <"Description of the location of the findings"> > ["at0024"] = < text = <"Surrounds"> description = <"Description of immediate surrounds to object"> > ["at0027"] = < text = <"Surface"> description = <"A description of the surface"> > ["at0028"] = < text = <"Edge"> description = <"Findings about the edge of the object under inspection"> > ["at0029"] = < text = <"Definition"> description = <"The nature of the edge of the object of examination"> > ["at0030"] = < text = <"Well defined"> description = <"The edge is clearly defined"> > ["at0031"] = < text = <"Moderately defined"> description = <"The edge is defined but less clear in places"> > ["at0032"] = < text = <"Poorly defined"> description = <"The edge is not defined clearly in many places"> > ["at0033"] = < text = <"Description"> description = <"Description of the edge or border of the object of inspection"> > ["at0034"] = < text = <"Translucent"> description = <"Is the object of inspection translucent?"> > ["at0036"] = < text = <"Colour description"> description = <"The colour of the object under inspection"> > ["at0048"] = < text = <"Clinical Description"> description = <"Clinical description of the findings on inspection"> > ["at0049"] = < text = <"Detail"> description = <"Detailed examination of a finding on inspection"> > ["at0050"] = < text = <"Drawing"> description = <"A drawing of the findings on inspection"> > ["at0051"] = < text = <"Contour"> description = <"The contour of the object of inspection"> > ["at0052"] = < text = <"Cluster: Exam"> description = <"Exam details"> > > > >