archetype (adl_version=1.4; uid=8808bc17-0674-4b14-84f2-3d377aed8254) openEHR-EHR-OBSERVATION.exam.v1 concept [at0000] -- Physical examination findings language original_language = <[ISO_639-1::en]> translations = < ["es-ar"] = < language = <[ISO_639-1::es-ar]> author = < ["name"] = <"Edgardo Vazquez"> ["organisation"] = <"VinculoMedico"> > accreditation = <"Medical Doctor"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> author = < ["name"] = <"Mona Saleh"> > > ["sl"] = < language = <[ISO_639-1::sl]> author = < ["name"] = <"Uroš Rajkovič, Biljana Prinčič"> ["organisation"] = <"Slovenia"> > > ["zh-cn"] = < language = <[ISO_639-1::zh-cn]> author = < ["name"] = <"Lin Zhang"> ["organisation"] = <"BIPH"> ["email"] = <"linforest@163.com"> > accreditation = <"?"> > > description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"2007-11-10"> > details = < ["zh-cn"] = < language = <[ISO_639-1::zh-cn]> purpose = <"用于记录关于对于特定主体对象体格检查发现的详情。"> use = <"用于记录关于对于特定主体对象体格检查发现的详情。其中，可包括关于这些发现的叙述型描述、一种用于嵌套若干详细的群簇（CLUSTER）型原始型的框架以及关于这些发现的临床解释。 关于群簇（CLUSTER）型检查原始型的例子包括那些用于详细描述望诊、触诊、听诊、叩诊以及身体系统运动或者解剖结构的原始型，如瞳孔检查原始型CLUSTER.exam_pupils。 对于现有临床系统之中临床发现的叙述型描述，可以采用名为“Description”（描述）的数据元进行采集。 临床医生有时可能希望采用“慢性中耳炎”之类的概括性短语来记录对于体格检查的解释。在当前体格检查原始型的语境下，仅仅应当将其理解为“体征与慢性中耳炎相符或者说相一致”。尽管这种概括性短语可能看似用来表示某种诊断，但就安全一致的查询来说，依然需要采用问题诊断原始型EVALUATION.problem_diagnosis来记录诊断，即使是二者所采用的短语完全相同。"> keywords = <"临床", "体格检查", "检查", "发现", "所见", "查体"> misuse = <"并非旨在用于记录病史采集类观察项目——此时请采用具体的观察（OBSERVATION）型和群簇（CLUSTER）型原始型。例如，纪事原始型OBSERVATION.story和症状原始型CLUSTER.symptom。 并非旨在用于记录单独的临床观察项目——此时请采用具体的观察（OBSERVATION）型原始型。例如，血压原始型OBSERVATION.blood_pressure、体重原始型OBSERVATION.body_weight，或者身高原始型OBSERVATION.height。"> copyright = <"© openEHR Foundation"> > ["sl"] = < language = <[ISO_639-1::sl]> purpose = <"Za beleženje znakov izmerjenih v okviru fizikalnega pregleda"> use = <"\"Container\" za gnezdenje \"cluster\"-jev, ki podrobno opisujejo posamezne elemente fizikalnega pregleda vključujoč pregled, tipanje, avskultacijo (osluškovanje) in udarjanje (skupine vključno z njihovimi specializacijami). cluster - skupina, grozd"> keywords = <"pregled", "fizikalni"> misuse = <"*Not to be used for recording history-taking observations - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure, OBSERVATION.body_weight, or OBSERVATION.height.(en)"> copyright = <"© openEHR Foundation"> > ["es-ar"] = < language = <[ISO_639-1::es-ar]> purpose = <"Para registrar una descripcion narrativa e interpretacion clinica de los hallazgos observados durante el examen fisico completo de una persona, y proveer un marco de referencia para anidar CLUSTER de arquetipos detallados, cada uno de los cuales posibilita registrar en detalle aspectos especificos del examen fisico"> use = <"Utilizar para registrar una descripcion narrativa de los hallazgos observados durante el examen fisico general de una persona. Utilizar para incorporar la descripcion narrativa de hallazgos clinicos dentro de sistemas clinicos actuales o legados a un formato de arquetipos, utilizando el elemento de data \"Descripcion Clinica\". Utilizar como un arquetipo contenedor - para proveer un arquetipo ENTRY consultable en el cual, puedan ser anidados arquetipos CLUSTER especificos de examenes, incluidos aquellos que detallan la inspeccion, palpacion, asucultacion, percusion y movimiento de los sistemas o estructuras anatomicas del cuerpo"> keywords = <"examen", "fisico", "examen", "hallazgos", "clinicos"> misuse = <"No debe ser utilizado para registrar observaciones de la toma de historia -utilizar arquetipos especificos de OBSERVACION y CLUSTER. Por ejemplo OBSERVACION.historia y CLUSTER.sintoma. No debe ser utilizado para registrar observaciones clinicas autonomas - utilizar arquetipos especificos OBSERVATION. Por ejemplo OBSERVATION.presion_arterial, OBSERVATION.peso_corporal, u OBSERVATION.altura. "> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording details about findings on physical examination of the subject of care."> use = <"Use to record details about findings on physical examination of the subject of care. This may include a narrative description of the findings, a framework in which to nest detailed CLUSTER examination archetypes, and a clinical interpretation of the findings. Examples of detailed CLUSTER examination archetypes include those that describe inspection, palpation, auscultation, percussion and movement of body systems or anatomical structures, such as CLUSTER.exam_pupils. Narrative descriptions of clinical findings from existing clinical systems may be captured using the 'Description' data element. Clinicians may sometimes want to record a summative phrase such as 'chronic otitis media' as an Interpretation of the physical examination. In the context of the physical examination archetype this should only be understood as 'physical signs are consistent with chronic otitis media'. While the summative phrase may appear to represent a diagnosis, safe and consistent querying requires a diagnosis to be recorded using the EVALUATION.problem_diagnosis archetype, even if the phrases are identical."> keywords = <"examination", "physical", "exam", "findings", "clinical"> misuse = <"Not to be used for recording history-taking observations - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure, OBSERVATION.body_weight, or OBSERVATION.height."> copyright = <"© openEHR Foundation"> > ["ar-sy"] = < language = <[ISO_639-1::ar-sy]> purpose = <"لتسجيل الموجودات التي تم العثور عليها عند الفحص البدني"> use = <"تم تصميم النموذج ليحتوي على عناقيد مفصلة متعلقة بالفحص بما في ذلك الاكتشاف, الجس, التسمع و القرع بما في هذه العناقيد من تخصيصات."> keywords = <"الفحص", "البدني"> misuse = <""> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"published"> other_contributors = <"Sheryl Alexander, NT Department of Health, Australia", "Tomas Alme, DIPS, Norway", "Nadim Anani, Karolinska Institutet, Sweden", "Rita Apelt, Department of Health,NT, Australia", "Silje Bakke, Bergen Hospital Trust, Norway", "Margaret Campbell, Queensland Health, Australia", "Rong Chen, Cambio Healthcare Systems, Sweden", "Stephen Chu, NeHTA, Australia", "Margaret Cotter, AMSANT, Australia", "Michelle Dowden, Miwatj Health Ngalkanbuy Health, Australia", "Samo Drnovsek, Marand ltd, Slovenia", "Tim Garden, NTG Department of Health, Australia", "Tanya Gardner, CAAC, Australia", "Sam Heard, Ocean Informatics, Australia (Editor)", "Lars Karlsen, DIPS ASA, Norway", "Russell Leftwich, Russell B Leftwich MD, United States", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Ocean Informatics, Australia (Editor)", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (Editor)", "Jeremy Oats, NT Health, Australia", "Steven Schatz, Department of Health (Northern Territory), Australia", "Anoop Shah, University College London, United Kingdom", "Cherie Whitbread, Royal Darwin Hospital, Australia", "Jo Wright, NT Dept of Health, Australia (Editor)", "Lin Zhang, BIPH, China"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> ["custodian_organisation"] = <"Ocean Informatics"> ["current_contact"] = <"Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com"> ["original_namespace"] = <"com.oceaninformatics"> ["original_publisher"] = <"Ocean Informatics"> ["custodian_namespace"] = <"com.oceaninformatics"> ["MD5-CAM-1.0.1"] = <"CA38F813160C7B970E1C4F6118F74BC7"> ["build_uid"] = <"7f19f635-b13f-48cd-a6d3-2037b23f9550"> ["revision"] = <"1.0.0"> > definition OBSERVATION[at0000] matches { -- Physical examination findings data matches { HISTORY[at0001] matches { -- Event Series events cardinality matches {1..*; unordered} matches { EVENT[at0002] occurrences matches {0..*} matches { -- Any event data matches { ITEM_TREE[at0003] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0004] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches { -- Examination detail include archetype_id/value matches {/.*/} } ELEMENT[at0006] occurrences matches {0..*} matches { -- Interpretation value matches { DV_TEXT matches {*} } } ELEMENT[at0011] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } } } } state matches { ITEM_TREE[at0009] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0008] occurrences matches {0..*} matches { -- Confounding factors value matches { DV_TEXT matches {*} } } } } } } } } } protocol matches { ITEM_TREE[at0007] matches { -- Tree items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER[at0010] occurrences matches {0..*} matches { -- Device details include archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype CLUSTER[at0012] occurrences matches {0..*} matches { -- Extension include archetype_id/value matches {/.*/} } } } } } ontology term_definitions = < ["ar-sy"] = < items = < ["at0000"] = < text = <"*Physical Examination Findings(en)"> description = <"*Findings observed during the physical examination of a subject.(en)"> > ["at0001"] = < text = <"*Event Series(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"*Any event(en)"> description = <"*Unspecified point in time which may be explicitly defined in a template or at run-time.(en)"> > ["at0003"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0004"] = < text = <"*Description(en)"> description = <"*Narrative description of the overall findings observed during a physical examination of a patient.(en)"> comment = <"*May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format.(en)"> > ["at0005"] = < text = <"*Examination Detail(en)"> description = <"*Structured details of the physical examination.(en)"> comment = <"*Detailed clinical findings will be recorded as CLUSTER archetypes which can then be nested within this SLOT to represent the fractal nature of clinical examination and allow for variation in clinician's requirements for examination documentation. For example: CLUSTER.palpation_of_uterus, CLUSTER.palpation_of_cervix and CLUSTER.palpation_of_fetus can be nested in this slot or within each other to represent the specific requirements of clinicians working in the obstetric domains - content, priorities and level of detail will differ depending on clinical context, professional background and specialty.(en)"> > ["at0006"] = < text = <"*Interpretation(en)"> description = <"*Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings.(en)"> comment = <"*Coding with a terminology is preferred, if possible. For example, normal examination or chronic otitis media.(en)"> > ["at0007"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0008"] = < text = <"*Confounding Factors(en)"> description = <"*Description of any incidental factors that may have contributed to the physical examination findings.(en)"> > ["at0009"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0010"] = < text = <"*Device Details(en)"> description = <"*Details about any device used during the physical examination.(en)"> > ["at0011"] = < text = <"*Comment(en)"> description = <"*Any additional narrative comment not covered by other elements.(en)"> > ["at0012"] = < text = <"*Cluster(en)"> description = <"**(en)"> > > > ["sl"] = < items = < ["at0000"] = < text = <"Ugotovitve pregleda"> description = <"Za dokumentiranje ugotovitev/znakov fizikalnega pregleda subjekta"> > ["at0001"] = < text = <"*Event Series(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"*Any event(en)"> description = <"*Unspecified point in time which may be explicitly defined in a template or at run-time.(en)"> > ["at0003"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0004"] = < text = <"Klinični opis"> description = <"Beleženje ugotovljenih dejstev pri pregledu"> comment = <"*May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format.(en)"> > ["at0005"] = < text = <"*Examination Detail(en)"> description = <"*Structured details of the physical examination.(en)"> comment = <"*Detailed clinical findings will be recorded as CLUSTER archetypes which can then be nested within this SLOT to represent the fractal nature of clinical examination and allow for variation in clinician's requirements for examination documentation. For example: CLUSTER.palpation_of_uterus, CLUSTER.palpation_of_cervix and CLUSTER.palpation_of_fetus can be nested in this slot or within each other to represent the specific requirements of clinicians working in the obstetric domains - content, priorities and level of detail will differ depending on clinical context, professional background and specialty.(en)"> > ["at0006"] = < text = <"*Interpretation(en)"> description = <"*Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings.(en)"> comment = <"*Coding with a terminology is preferred, if possible. For example, normal examination or chronic otitis media.(en)"> > ["at0007"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0008"] = < text = <"*Confounding Factors(en)"> description = <"*Description of any incidental factors that may have contributed to the physical examination findings.(en)"> > ["at0009"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0010"] = < text = <"*Device Details(en)"> description = <"*Details about any device used during the physical examination.(en)"> > ["at0011"] = < text = <"*Comment(en)"> description = <"*Any additional narrative comment not covered by other elements.(en)"> > ["at0012"] = < text = <"*Cluster(en)"> description = <"**(en)"> > > > ["es-ar"] = < items = < ["at0000"] = < text = <"Hallazgos del Examen Fisico"> description = <"Hallazgos observados durante el examen fisico de una persona"> > ["at0001"] = < text = <"*Event Series(en)"> description = <"*@ internal @(en)"> > ["at0002"] = < text = <"*Any event(en)"> description = <"*Unspecified point in time which may be explicitly defined in a template or at run-time.(en)"> > ["at0003"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0004"] = < text = <"Descripcion"> description = <"Descripcion narrativa de los hallazgos generales observados durante un examen fisico de un paciente"> comment = <"Puede ser utilizado para registrar un resumen narrativo del examen clinico completo o aspectos claves de los hallazgos del examen clinico, que sera apoyado con data estructurada. Los detalles de hallazgos especificos estructurados pueden ser incluidos utilizando arquetipos CLUSTER en el espacio \"Detalles del Examen\". Este elemento de data puede ser utilizado para capturar data legada que no esta disponble en un formato estructurado."> > ["at0005"] = < text = <"*Examination Detail(en)"> description = <"*Structured details of the physical examination.(en)"> comment = <"*Detailed clinical findings will be recorded as CLUSTER archetypes which can then be nested within this SLOT to represent the fractal nature of clinical examination and allow for variation in clinician's requirements for examination documentation. For example: CLUSTER.palpation_of_uterus, CLUSTER.palpation_of_cervix and CLUSTER.palpation_of_fetus can be nested in this slot or within each other to represent the specific requirements of clinicians working in the obstetric domains - content, priorities and level of detail will differ depending on clinical context, professional background and specialty.(en)"> > ["at0006"] = < text = <"Interpretacion"> description = <"Palabra, frase o descripcion breve que represente el significado clinico e importancia de los hallazgos del examen fisico"> comment = <"Se prefiere la dodificacion con una terminologia. Por ejemplo, examen normal u otitis media cronica"> > ["at0007"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0008"] = < text = <"Factores de Confusion"> description = <"Descripcion de cualquier factor incidental que pueda haber contribuido a los hallazgos del examen físico"> > ["at0009"] = < text = <"*Tree(en)"> description = <"*@ internal @(en)"> > ["at0010"] = < text = <"Detalle del dispositivo"> description = <"Detalles acerca de cualquier dispositivo utilizado durante el examen fisico."> > ["at0011"] = < text = <"Comentario"> description = <"Cualquier comentario narrativo adicional no incluido por otros elementos"> > ["at0012"] = < text = <"*Cluster(en)"> description = <"**(en)"> > > > ["en"] = < items = < ["at0000"] = < text = <"Physical examination findings"> description = <"Findings observed during the physical examination of a subject of care."> > ["at0001"] = < text = <"Event Series"> description = <"@ internal @"> > ["at0002"] = < text = <"Any event"> description = <"Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time."> > ["at0003"] = < text = <"Tree"> description = <"@ internal @"> > ["at0004"] = < text = <"Description"> description = <"Narrative description of the overall findings observed during a physical examination of a patient."> comment = <"May be used to record a narrative summary of the complete clinical examination or key aspects of clinical examination findings, which will be supported by structured data. Details of specific structured findings can be included using CLUSTER archetypes in the 'Examination Detail' slot. This data element may be used to capture legacy data that is not available in a structured format."> > ["at0005"] = < text = <"Examination detail"> description = <"Structured details of the physical examination."> comment = <"Detailed clinical findings will be recorded as CLUSTER archetypes which can be nested within this SLOT to represent the fractal nature of clinical examination and allow for variation in clinician's requirements for examination documentation. For example: CLUSTER.palpation_of_uterus, CLUSTER.palpation_of_cervix and CLUSTER.palpation_of_fetus can be nested in this slot or within each other to represent the specific requirements of clinicians working in the obstetric domains - content, priorities and level of detail will differ depending on clinical context, professional background and specialty."> > ["at0006"] = < text = <"Interpretation"> description = <"Single word, phrase or brief description which represents the clinical meaning and significance of the physical examination findings."> comment = <"Coding with a terminology is preferred, if possible. For example, 'normal examination' or 'tympanic membrane perforation'. "> > ["at0007"] = < text = <"Tree"> description = <"@ internal @"> > ["at0008"] = < text = <"Confounding factors"> description = <"Description of any incidental factors that may have contributed to the physical examination findings."> > ["at0009"] = < text = <"Tree"> description = <"@ internal @"> > ["at0010"] = < text = <"Device details"> description = <"Details about any device used during the physical examination."> > ["at0011"] = < text = <"Comment"> description = <"Additional narrative about the overall physical examination findings not captured in other fields."> > ["at0012"] = < text = <"Extension"> description = <"Additional information required to capture local content or to align with other reference models/formalisms."> comment = <"e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents."> > > > ["zh-cn"] = < items = < ["at0000"] = < text = <"体格检查发现"> description = <"对于特定主体对象进行体格检查过程中所获得的发现。"> > ["at0001"] = < text = <"Event Series"> description = <"@ internal @"> > ["at0002"] = < text = <"任何事件"> description = <"默认值，未加具体说明的，而可以在特定模板中或在运行时加以明确定义的时刻（时间点）型或时段（时间段、时间区间）型事件。"> > ["at0003"] = < text = <"Tree"> description = <"@ internal @"> > ["at0004"] = < text = <"描述"> description = <"关于特定患者的体格检查过程中所观察到的全部发现的叙述型描述。"> comment = <"可用于记录关于整个临床检查或者临床检查发现关键方面（将采用结构化数据加以支持）的叙述型摘要。在检查细节槽位“Examination Detail”之中，可以利用群簇（CLUSTER）型原始型来包括关于具体结构化发现的细节。该数据元可用于采集和记录并未采用某种结构化格式的历史遗留数据。"> > ["at0005"] = < text = <"检查细节"> description = <"体格检查的结构化细节。"> comment = <"详细的临床发现将被记录为可以嵌套在该槽位（SLOT ）之中的群簇（CLUSTER）型原始型，用于表达临床检查的分形特性，并顾及到不同临床医生对于检查文档记录需求的差异。例如，可以将子宫扪诊群簇型原始型CLUSTER.palpation_of_uterus、宫颈扪诊群簇型原始型CLUSTER.palpation_of_cervix和胎儿扪诊群簇型原始型CLUSTER.palpation_of_fetus嵌套在该槽位之中，或者它们相互嵌套，以便表达在产科学领域工作的临床医师的特殊需求——根据临床语境、专业背景以及专业的不同，内容、优先级别和详细程度将会有所不同。"> > ["at0006"] = < text = <"解释"> description = <"用于表示体格检查发现的临床含义和意义的单个词语、短语或简要描述。"> comment = <"在可能的情况下，首选采用特定的术语集进行编码。例如，“检查正常”或“鼓膜穿孔”。"> > ["at0007"] = < text = <"Tree"> description = <"@ internal @"> > ["at0008"] = < text = <"干扰因素"> description = <"关于可能对体格检查发现做出了贡献的任何偶然因素的描述。"> > ["at0009"] = < text = <"Tree"> description = <"@ internal @"> > ["at0010"] = < text = <"装置细节"> description = <"关于体格检查过程中所使用的任何装置的细节。"> > ["at0011"] = < text = <"注释"> description = <"其他字段之中并未采集的关于全部体格检查发现的叙述型注释。"> > ["at0012"] = < text = <"扩展"> description = <"采集本地内容或者与其他参考模型/形式化体系进行映射时所需的额外信息。"> comment = <"例如，本地信息需求，或者是与FHIR或CIMI等价模型映射时所需的额外元数据。"> > > > >