archetype (adl_version=1.4)
openEHR-EHR-CLUSTER.exam-chest.v1
specialize
openEHR-EHR-CLUSTER.exam.v1
concept
[at0000.1]
language
original_language = <[ISO_639-1::en]>
description
original_author = <
["name"] = <"Sam Heard">
["organisation"] = <"Ocean Informatics">
["date"] = <"9/04/2007">
["email"] = <"Sam.Heard@OceanInformatics.biz">
>
details = <
["en"] = <
language = <[ISO_639-1::en]>
purpose = <"A cluster for recording findings on physical examination of the chest">
use = <"">
keywords = <"examination", "physical", "chest", "thorax", "lungs">
misuse = <"">
>
>
lifecycle_state = <"Initial">
other_contributors = <>
definition
CLUSTER[at0000.1] ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
CLUSTER[at0004] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
ELEMENT[at0005] occurrences ∈ {0..*} ∈ {
value ∈ {
DV_TEXT ∈ {*}
}
}
}
}
ELEMENT[at0002] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_TEXT ∈ {*}
}
}
CLUSTER[at0008] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
CLUSTER[at0.1] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
ELEMENT[at0.2] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_CODED_TEXT ∈ {
defining_code ∈ {[local::]}
}
}
}
ELEMENT[at0.28] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_TEXT ∈ {*}
}
}
CLUSTER[at0.30] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
ELEMENT[at0.31] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_BOOLEAN ∈ {
value ∈ {True, False}
}
}
}
CLUSTER[at0.32] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
ELEMENT[at0.33] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_BOOLEAN ∈ {
value ∈ {True, False}
}
}
}
ELEMENT[at0.34] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_TEXT ∈ {*}
}
}
}
}
}
}
allow_archetype CLUSTER occurrences ∈ {0..1} ∈ {
include
archetype_id/value matches {/palpation\.v1draft/}
archetype_id/value matches {/inspection\.v1draft/}
archetype_id/value matches {/auscultation-chest\.v1/}
}
}
}
CLUSTER[at0.3] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
ELEMENT[at0.4] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_CODED_TEXT ∈ {
defining_code ∈ {
[local::
at0.5,
at0.6,
at0.7]
}
}
}
}
CLUSTER[at0.8] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
ELEMENT[at0.19] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_TEXT ∈ {*}
}
}
ELEMENT[at0.9] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_CODED_TEXT ∈ {
defining_code ∈ {
[local::
at0.10,
at0.11]
}
}
}
}
ELEMENT[at0.12] occurrences ∈ {0..1} ∈ {
value ∈ {
5|[local::at0.13],
6|[local::at0.14],
8|[local::at0.15],
10|[local::at0.16]
}
}
CLUSTER[at0.17] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
ELEMENT[at0.18] occurrences ∈ {0..*} ∈ {
value ∈ {
DV_CODED_TEXT ∈ {
defining_code ∈ {
[local::
at0.25,
at0.20,
at0.24,
at0.23,
at0.21,
at0.22]
}
}
}
}
}
}
ELEMENT[at0.26] occurrences ∈ {0..1} ∈ {
value ∈ {
DV_BOOLEAN ∈ {
value ∈ {True, False}
}
}
}
}
}
}
}
CLUSTER[at0003] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
allow_archetype CLUSTER occurrences ∈ {0..1} ∈ {
include
archetype_id/value matches {/exam-generic\.v1/}
archetype_id/value matches {/auscultation-chest\.v1/}
archetype_id/value matches {/palpation\.v1/}
archetype_id/value matches {/inspection\.v1draft/}
archetype_id/value matches {/percussion\.v1/}
}
}
}
}
}
CLUSTER[at0.27] occurrences ∈ {0..1} ∈ {
items cardinality ∈ {0..*; unordered} ∈ {
allow_archetype CLUSTER occurrences ∈ {0..1} ∈ {
include
archetype_id/value matches {/exam-generic-lympnode\.v1/}
}
}
}
ELEMENT[at0006] occurrences ∈ {0..*} ∈ {
value ∈ {
DV_MULTIMEDIA ∈ {
media_type ∈ {
[openEHR::
426,
427,
429]
}
}
}
}
}
}
ontology
term_definitions = <
["en"] = <
items = <
["at0.1"] = <
description = <"Findings about the chest wall">
text = <"Chest wall">
>
["at0.10"] = <
description = <"Breathing using the diaphragm and not the chest wall">
text = <"Diaphragmatic breathing">
>
["at0.11"] = <
description = <"Breathing using expansion of the chest wall">
text = <"Thoracic breathing">
>
["at0.12"] = <
description = <"Effort required for breathing">
text = <"Effort">
>
["at0.13"] = <
description = <"Diaphragmatic breathing as at rest">
text = <"Normal breathing effort">
>
["at0.14"] = <
description = <"Breathing using obvious chest expansion">
text = <"Mild increase in effort">
>
["at0.15"] = <
description = <"Breathing with signs of abnormal breathing">
text = <"Moderate increased effort">
>
["at0.16"] = <
description = <"Many signs of increased breathing effort">
text = <"Major increased effort">
>
["at0.17"] = <
description = <"Signs of increased respiratory effort">
text = <"Signs of increased effort">
>
["at0.18"] = <
description = <"Use of accessory respiratory muscles">
text = <"Sign">
>
["at0.19"] = <
description = <"Description of breathing">
text = <"Description">
>
["at0.2"] = <
description = <"The contour of the chest wall">
text = <"Description">
>
["at0.20"] = <
description = <"Drawing in between the ribs on inspiration">
text = <"Intercostal recession">
>
["at0.21"] = <
description = <"Drawing in of the sternum on inspiration">
text = <"Sternal recession">
>
["at0.22"] = <
description = <"Indrawing of the chest wall on inspiration">
text = <"Rib retraction">
>
["at0.23"] = <
description = <"Indrawing above the sternum on inspiration">
text = <"Suprasternal recession">
>
["at0.24"] = <
description = <"Indrawing of the subcostal abdominal wall ">
text = <"Subcostal recession">
>
["at0.25"] = <
description = <"Use of accessory respiratory muscles during inspiration">
text = <"Using accessory muscles">
>
["at0.26"] = <
description = <"Any paradoxical movement of the chest wall during respiration">
text = <"Paradoxical movement (flail chest)">
>
["at0.27"] = <
description = <"Lymphnodes">
text = <"Lymph nodes">
>
["at0.28"] = <
description = <"The shape of the chest">
text = <"Shape">
comment = <"ChestShape SNOMED query">
>
["at0.29"] = <
description = <"Pidgeon chest, with prominent lower sternum">
text = <"Pectus carinatum">
>
["at0.3"] = <
description = <"Respiratory findings">
text = <"Respiratory system">
>
["at0.30"] = <
description = <"*">
text = <"Heart - Apex beat">
>
["at0.31"] = <
description = <"Apex beat is visible">
text = <"Visible">
>
["at0.32"] = <
description = <"*">
text = <"Palpation">
>
["at0.33"] = <
description = <"Apex beat is palpable">
text = <"Palpable">
>
["at0.34"] = <
description = <"Site of maximal location of apex beat">
text = <"Maximal location">
>
["at0.4"] = <
description = <"The position of the trachea">
text = <"Trachea">
>
["at0.5"] = <
description = <"The trachea is in the midline position">
text = <"Midline">
>
["at0.6"] = <
description = <"The trachea is deviated to the left">
text = <"Deviated to the left">
>
["at0.7"] = <
description = <"The trachea is deviated to the right">
text = <"Deviated to the right">
>
["at0.8"] = <
description = <"Findings about breathing">
text = <"Breathing">
>
["at0.9"] = <
description = <"Type of breathing">
text = <"Type">
>
["at0000"] = <
description = <"Basic examination cluster for describing findings on physical examination when there is no named focus of examination">
text = <"Examination">
>
["at0000.1"] = <
description = <"For recording findings on physical examination of the chest wall and lungs">
text = <"Examination of the chest">
>
["at0002"] = <
description = <"Textural description of the part examined">
text = <"Clinical description">
>
["at0003"] = <
description = <"More focused examination findings">
text = <"Detail">
>
["at0004"] = <
description = <"A group of statements about the normality of the examination">
text = <"Normal statements">
>
["at0005"] = <
description = <"A specific statement of normality">
text = <"Normal statement">
>
["at0006"] = <
description = <"Drawing or image of the area examined">
text = <"Image">
>
["at0008"] = <
description = <"Clinical findings">
text = <"Findings">
>
>
>
>