archetype (adl_version=1.4; uid=01d5c63a-781a-4612-8da7-14827608c1a5) openEHR-EHR-CLUSTER.exam_auditory_canal.v1 concept [at0000] -- Examination of external auditory canal language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["email"] = <"heather.leslie@oceaninformatics.com"> ["date"] = <"2012-09-03"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording a narrative description and clinical interpretation of the findings observed during the physical examination of XYZ."> use = <"Use to record a narrative description of the overall findings observed during the physical examination of external auditory canal. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.exam_ears archetype, but can also be used within the OBSERVATION.exam and other OBSERVATION or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, CLUSTER.exam_tympanic_membrane or CLUSTER.exam_middle_ear. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element."> misuse = <"Not to be used for recording data not related to other parts of the ear such as the Pinna or Middle ear - use the specific archetypes, CLUSTER.exam_pinna and CLUSTER.exam_middle_ear. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.audiogram_result."> copyright = <"© Northern Territory Department of Health, Australia, openEHR Foundation"> > > lifecycle_state = <"published"> other_contributors = <"Heather Leslie, Ocean Informatics, Australia (nehta Editor)", "Silje Ljosland Bakke, Bergen Hospital Trust, Norway", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom", "John Tore Valand, Haukeland Universitetssjukehus, Norway", "Stephen Chu, NEHTA, Australia", "Harvey Coates, UWA, Australia", "Marissa Cookson, Dept of Health, Australia", "Kimberley Crebbin, NT Hearing Services, Australia", "Graeme Crossland, Northern Territory, Australia", "Kathy Currie, Northern Territory Health, Australia", "Jacques de Haan, Alice Springs Hospital, Australia", "Jade Frederiksen, Hearing Health Program, DoH, Australia", "Sam Heard, Ocean Informatics, Australia (Editor)", "Paul Hickey, Hearing Health Program, Australia", "Oliver Hosking, Remote Health NT, Australia", "Amanda Leach, Menzies School of Health Research, Australia", "Anthony Leech, Hearing Health, Australia", "Kerrie Lee, Ngaanyatjarra Health Service, Australia", "Heather Leslie, Ocean Informatics, Australia (Editor)", "Ian McNicoll, Ocean Informatics, United Kingdom", "Hemi Patel, Royal Darwin Hospital, Australia", "Mark Ramjan, NT Department of Health, Australia", "Fiona Wake, RAHC, Australia", "Christine Wigger, Menzies School of Health Research, Australia"> 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"> ["references"] = <"Direct communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program. Northern Territory Government, Department of Health: Hearing Health Program ENT Specialist Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Teleotology Nurse Consultation Form 2011 12 07. Northern Territory Government, Department of Health: Northern Territory Hearing Health Program Audiologist Consultation Form 2011 12 07. OATSIH: The Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations (2010). Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25792800821BE8?OpenDocument."> ["original_namespace"] = <"com.oceaninformatics"> ["original_publisher"] = <"Ocean Informatics"> ["custodian_namespace"] = <"com.oceaninformatics"> ["MD5-CAM-1.0.1"] = <"FEB3117E30660226B39CA9E398EF25A7"> ["build_uid"] = <"c62dd47f-cdfb-481f-9ae8-2cd66eabf43c"> ["revision"] = <"1.0.0"> > definition CLUSTER[at0000] matches { -- Examination of external auditory canal 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:: at0009, -- Left at0010] -- Right } } } } ELEMENT[at0002] occurrences matches {0..1} matches { -- No abnormality detected value matches { DV_BOOLEAN matches { value matches {True} } } } ELEMENT[at0003] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } ELEMENT[at0011] occurrences matches {0..1} matches { -- Wax description value matches { DV_TEXT matches {*} } } ELEMENT[at0012] occurrences matches {0..1} matches { -- Canal tenderness value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0013, -- Present at0014] -- Absent } } } } ELEMENT[at0015] occurrences matches {0..1} matches { -- Offensive odour value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0016, -- Present at0017] -- Absent } } } } ELEMENT[at0018] occurrences matches {0..1} matches { -- Discharge presence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0019, -- Present at0020] -- Absent } } } } ELEMENT[at0021] occurrences matches {0..1} matches { -- Discharge type value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0022, -- Blood-stained at0023, -- Haemoserous at0024, -- Mucoid at0025, -- Mucopurulent at0026, -- Purulent at0027] -- Serous } } } } ELEMENT[at0028] occurrences matches {0..1} matches { -- Discharge amount value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0029, -- Scant at0030, -- Moderate at0031] -- Profuse } } } } ELEMENT[at0032] occurrences matches {0..1} matches { -- Discharge description value matches { DV_TEXT matches {*} } } ELEMENT[at0033] occurrences matches {0..1} matches { -- Foreign body presence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0034, -- Present at0035] -- Absent } } } } ELEMENT[at0036] occurrences matches {0..1} matches { -- Foreign body location value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0037, -- Outer Canal at0038, -- Deep Canal at0039] -- Middle ear } } } } allow_archetype CLUSTER[at0004] occurrences matches {0..*} matches { -- Examination findings include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam_tympanic_membrane(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.exam_middle_ear(-[a-zA-Z0-9_]+)*\.v1/} } allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches { -- Multimedia representation include archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0006] occurrences matches {0..*} matches { -- Clinical interpretation value matches { DV_TEXT matches {*} } } ELEMENT[at0007] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Examination not done include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/} } } } ontology term_definitions = < ["en"] = < items = < ["at0000"] = < text = <"Examination of external auditory canal"> description = <"Findings observed during the physical examination of the external auditory canal."> > ["at0001"] = < text = <"Ear examined"> description = <"Identification of the ear under examination."> > ["at0002"] = < text = <"No abnormality detected"> description = <"Statement that no abnormality was detected (NAD) on physical examination."> 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."> > ["at0003"] = < text = <"Clinical description"> description = <"Narrative description of the overall findings observed during the physical examination of the external auditory canal."> > ["at0004"] = < text = <"Examination findings"> description = <"Structured details about the physical examination findings."> > ["at0005"] = < text = <"Multimedia representation"> description = <"Digital image, video or diagram representing the physical examination findings."> > ["at0006"] = < text = <"Clinical interpretation"> description = <"Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings."> > ["at0007"] = < text = <"Comment"> description = <"Additional narrative about the physical examination findings, not captured in other fields."> > ["at0008"] = < text = <"Examination not done"> description = <"Details to explicitly record that this examination was not performed."> > ["at0009"] = < text = <"Left"> description = <"The left ear was examined."> > ["at0010"] = < text = <"Right"> description = <"The right ear was examined."> > ["at0011"] = < text = <"Wax description"> description = <"Narrative description of the wax findings in the external auditory canal."> > ["at0012"] = < text = <"Canal tenderness"> description = <"Presence of tenderness in the external auditory canal."> > ["at0013"] = < text = <"Present"> description = <"Tenderness is noted in the external auditory canal wall."> > ["at0014"] = < text = <"Absent"> description = <"Tenderness is not noted in the external auditory canal wall."> > ["at0015"] = < text = <"Offensive odour"> description = <"Presence of any offensive odour originating from the external auditory canal."> > ["at0016"] = < text = <"Present"> description = <"An offensive odour is noted as originating from the external auditory canal."> > ["at0017"] = < text = <"Absent"> description = <"No odour is noted as originating from the external auditory canal."> > ["at0018"] = < text = <"Discharge presence"> description = <"Presence of a discharge observed in the external auditory canal."> > ["at0019"] = < text = <"Present"> description = <"Discharge is observed within the ear canal."> > ["at0020"] = < text = <"Absent"> description = <"Discharge is not observed within the ear canal."> > ["at0021"] = < text = <"Discharge type"> description = <"Type of discharge observed in the external auditory canal or at the tympanic membrane."> > ["at0022"] = < text = <"Blood-stained"> description = <"The discharge appears to consist mostly of blood."> > ["at0023"] = < text = <"Haemoserous"> description = <"The discharge appears to consist of both blood and clear, watery fluid."> > ["at0024"] = < text = <"Mucoid"> description = <"The discharge appears to consist mostly of a thick, mucoid substance"> > ["at0025"] = < text = <"Mucopurulent"> description = <"The discharge appears to consist of both mucous and pus."> > ["at0026"] = < text = <"Purulent"> description = <"The discharge appears to consist mostly of pus."> > ["at0027"] = < text = <"Serous"> description = <"The discharge appears to consist mostly of clear, watery fluid."> > ["at0028"] = < text = <"Discharge amount"> description = <"Amount of discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0029"] = < text = <"Scant"> description = <"A small amount of discharge is observed in the external auditory canal."> > ["at0030"] = < text = <"Moderate"> description = <"A moderate amount of discharge is observed in the external auditory canal."> > ["at0031"] = < text = <"Profuse"> description = <"A profuse amount of discharge is observed in the external auditory canal."> > ["at0032"] = < text = <"Discharge description"> description = <"Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0033"] = < text = <"Foreign body presence"> description = <"Presence of a foreign body in the external auditory canal."> > ["at0034"] = < text = <"Present"> description = <"A foreign body is present in the external auditory canal."> > ["at0035"] = < text = <"Absent"> description = <"A foreign body is not present in the external auditory canal."> > ["at0036"] = < text = <"Foreign body location"> description = <"Location of the foreign body within the external auditory canal."> comment = <"This data element is redundant if a foreign body is absent from the canal."> > ["at0037"] = < text = <"Outer Canal"> description = <"The foreign body is located in the outer part of the external auditory canal."> > ["at0038"] = < text = <"Deep Canal"> description = <"The foreign body is located in the deep, inner part of the external auditory canal."> > ["at0039"] = < text = <"Middle ear"> description = <"The foreign body is located within the middle ear cavity."> > > > >