archetype (adl_version=1.4) openEHR-EHR-CLUSTER.inspection-tympanic_membrane.v1 specialise openEHR-EHR-CLUSTER.inspection.v1 concept [at0000.1] -- Inspection of Tympanic Membrane language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Ian McNicoll"> ["organisation"] = <"Ocean Informatics"> ["date"] = <"02/11/2007"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording the findings on inspection of the tympanic membrane"> use = <"For use with the exam clusters for recording findings on inspection of the tmpanic membrane"> keywords = <"inspect", "visual", "ear", "tympanic", "perforation", "drum"> misuse = <"Should only be used in the exam observation"> copyright = <"copyright (c) 2009 openEHR Foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <"Heather Leslie", ...> other_details = < ["references"] = <""> > definition CLUSTER[at0000.1] matches { -- Inspection of Tympanic Membrane 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_CODED_TEXT matches { defining_code matches {[local::at0.87]} -- Tympanic membrane normal } } } } } ELEMENT[at0048] occurrences matches {0..1} matches { -- Clinical Description value matches { DV_TEXT matches {*} } } CLUSTER[at0006] occurrences matches {0..1} matches { -- Findings items cardinality matches {0..*; unordered} matches { ELEMENT[at0036] occurrences matches {0..1} matches { -- Colour description value matches { DV_TEXT matches {*} } } 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[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[at0027] occurrences matches {0..1} matches { -- Surface value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.91, -- No evidence of inflammation at0.92] -- Evidence of inflammation } } } } ELEMENT[at0024] occurrences matches {0..1} matches { -- Surrounds value matches { DV_TEXT 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[at0034] occurrences matches {0..1} matches { -- Translucent value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.52] occurrences matches {0..1} matches { -- Adequacy of View value matches { 0|[local::at0.53], -- Unobscured 1|[local::at0.54], -- Slightly obscured 2|[local::at0.55], -- Moderately obscured 3|[local::at0.56], -- Mostly obscured 4|[local::at0.57] -- Totally obscured } } CLUSTER[at0.76] occurrences matches {0..1} matches { -- Specific Appearance items cardinality matches {0..*; unordered} matches { ELEMENT[at0.58] occurrences matches {0..*} matches { -- Clinical Description value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } ELEMENT[at0.93] occurrences matches {0..1} matches { -- Light Reflex present value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0051] occurrences matches {0..1} matches { -- Contour value matches { DV_TEXT matches {*} } } ELEMENT[at0.80] occurrences matches {0..1} matches { -- Retraction value matches { 0|[local::at0.81], -- No retraction 1|[local::at0.82], -- Slightly retracted 2|[local::at0.83], -- touches the ossicular chain 3|[local::at0.84], -- reaches the level of the promontory 4|[local::at0.85]; -- adheres to the promontory 0 -- assumed value } } ELEMENT[at0.90] occurrences matches {0..1} matches { -- Air/Fluid level visible? value matches { DV_BOOLEAN matches { value matches {True, False} } } } CLUSTER[at0.97] occurrences matches {0..1} matches { -- Scarring items cardinality matches {0..*; unordered} matches { ELEMENT[at0.94] occurrences matches {0..1} matches { -- Description of scarring value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.95, -- Evidence of Atrophy at0.96] -- Evidence of tympanosclerosis } } } } ELEMENT[at0.79] occurrences matches {0..1} matches { -- Clinical Description value matches { DV_TEXT matches {*} } } } } } } CLUSTER[at0.74] occurrences matches {0..1} matches { -- Ventilation Tube items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0.98] occurrences matches {0..*} matches { include archetype_id/value matches {/openEHR-EHR-CLUSTER\.tympanic_ventilation_tube\.v1/} } } } CLUSTER[at0.63] occurrences matches {0..1} matches { -- Perforation items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0.99] occurrences matches {0..*} matches { include archetype_id/value matches {/openEHR-EHR-CLUSTER\.inspection-tympanic_perforation\.v1/} } } } 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[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 = < ["at0.52"] = < text = <"Adequacy of View"> description = <"How good is the view of the membrane?"> > ["at0.53"] = < text = <"Unobscured"> description = <"The TM is not obscured"> > ["at0.54"] = < text = <"Slightly obscured"> description = <"The TM is slightly obscured"> > ["at0.55"] = < text = <"Moderately obscured"> description = <"The TM is moderately obscured"> > ["at0.56"] = < text = <"Mostly obscured"> description = <"The TM is mostly obscured"> > ["at0.57"] = < text = <"Totally obscured"> description = <"The TM is totally obscured"> > ["at0.58"] = < text = <"Clinical Description"> description = <"The general appearance of the tympanic membrane"> > ["at0.59"] = < text = <"Translucent"> description = <"The TM is translucent"> > ["at0.60"] = < text = <"Dull"> description = <"The TM is dull"> > ["at0.61"] = < text = <"Inflamed"> description = <"The TM is inflamed"> > ["at0.62"] = < text = <"Retracted"> description = <"The TM appears retracted"> > ["at0.63"] = < text = <"Perforation"> description = <"Details of any perforation"> > ["at0.64"] = < text = <"Drum perforated"> description = <"Is the Tympanic membrane perforated?"> > ["at0.65"] = < text = <"Size"> description = <"Size of the perforation"> > ["at0.66"] = < text = <"Site"> description = <"Site of the perforation"> > ["at0.67"] = < text = <"Middle ear structures"> description = <"Description of any middle ear structure visible"> > ["at0.68"] = < text = <"Grommet"> description = <"*"> > ["at0.69"] = < text = <"Grommet"> description = <"The status of any grommet inserted"> > ["at0.70"] = < text = <"Not inserted"> description = <"*"> > ["at0.71"] = < text = <"In situ"> description = <"*"> > ["at0.72"] = < text = <"Not in position"> description = <"*"> > ["at0.73"] = < text = <"Not visible"> description = <"*"> > ["at0.74"] = < text = <"Ventilation Tube"> description = <"Details of any ventilation tube inserted"> > ["at0.75"] = < text = <"Appearance"> description = <"*"> > ["at0.76"] = < text = <"Specific Appearance"> description = <"The appearance of the drum"> > ["at0.77"] = < text = <"Retraction"> description = <"Degree of retraction of the TM"> > ["at0.78"] = < text = <"Perforated"> description = <"*"> > ["at0.79"] = < text = <"Clinical Description"> description = <"Text Description of the appearance of the drum"> > ["at0.80"] = < text = <"Retraction"> description = <"Degree of tympanic membrane retraction (Sade classification)"> > ["at0.81"] = < text = <"No retraction"> description = <"Normal TM without retraction"> > ["at0.82"] = < text = <"Slightly retracted"> description = <"TM slighly retracted i.e tothe level of the annualt ligament"> > ["at0.83"] = < text = <"touches the ossicular chain"> description = <"TM touchs the ossicular chain"> > ["at0.84"] = < text = <"reaches the level of the promontory"> description = <"TM reaches the promontory without adhering to it "> > ["at0.85"] = < text = <"adheres to the promontory"> description = <"TM reaches the promontory and adheres to it"> > ["at0.86"] = < text = <"Both drums normal"> description = <"Both tympanic membranes are normal"> > ["at0.87"] = < text = <"Tympanic membrane normal"> description = <"*"> > ["at0.88"] = < text = <"new ordinal"> description = <"*"> > ["at0.89"] = < text = <"Fluid level visible"> description = <"*"> > ["at0.90"] = < text = <"Air/Fluid level visible?"> description = <"Is a fluid level visible behind the membrane?"> > ["at0.91"] = < text = <"No evidence of inflammation"> description = <"*"> > ["at0.92"] = < text = <"Evidence of inflammation"> description = <"*"> > ["at0.93"] = < text = <"Light Reflex present"> description = <"*"> > ["at0.94"] = < text = <"Description of scarring"> description = <"*"> > ["at0.95"] = < text = <"Evidence of Atrophy"> description = <"*"> > ["at0.96"] = < text = <"Evidence of tympanosclerosis"> description = <"*"> > ["at0.97"] = < text = <"Scarring"> description = <"*"> > ["at0.98"] = < text = <"Cluster: Ventilation tube"> description = <"*"> > ["at0.99"] = < text = <"Cluster: Perforation"> description = <"*"> > ["at0000"] = < text = <"Inspection"> description = <"The findings on physical examination by inspection"> > ["at0000.1"] = < text = <"Inspection of Tympanic Membrane"> description = <"The findings on physical examination by inspection of the tympanic membrane "> > ["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 = <"An image of the findings on inspection - drawing, photo or video"> > ["at0051"] = < text = <"Contour"> description = <"The contour of the object of inspection"> > ["at0052"] = < text = <"Cluster: Exam"> description = <"Exam details"> > > > >