archetype (adl_version=1.4) openEHR-EHR-CLUSTER.inspection-nails.v1draft specialize openEHR-EHR-CLUSTER.inspection.v1draft concept [at0000.1] -- Inspection of nails language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["date"] = <"7/04/2007"> ["email"] = <"heather.leslie@oceaninformatics.biz"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"Recording of findings on inspection of nails"> use = <"For use with the exam clusters for recording findings on inspection"> keywords = <"inspect", "visual"> misuse = <"Should only be used in the exam observation"> > > lifecycle_state = <"Initial"> other_contributors = <> definition CLUSTER[at0000.1] matches { -- Inspection of nails 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 {*} } } } } CLUSTER[at0006] occurrences matches {0..*} matches { -- Findings items cardinality matches {0..*; unordered} matches { ELEMENT[at0048] occurrences matches {0..1} matches { -- Clinical Description value matches { DV_TEXT matches {*} } } CLUSTER[at0.89] occurrences matches {0..1} matches { -- Clubbing items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/clubbing\.v1draft/} exclude archetype_id/value matches {/.*/} } } } CLUSTER[at0.90] occurrences matches {0..*} matches { -- Specific nail details items cardinality matches {0..*; unordered} matches { ELEMENT[at0022] occurrences matches {0..*} matches { -- Identify nail value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.53, -- Right thumbnail at0.54, -- Left Thumbnail at0.55, -- Right index fingernail at0.56, -- Left index fingernail at0.57, -- Right middle fingernail at0.58, -- Left middle fingernail at0.59, -- Right ring fingernail at0.60, -- Left ring fingernail at0.61, -- Right little fingernail at0.62, -- Left little fingernail at0.63, -- Right great/first toenail at0.64, -- Left great/first toenail at0.65, -- Right second toenail at0.66, -- Left second toenail at0.67, -- Right third toenail at0.68, -- Left third toenail at0.69, -- Right fourth toenail at0.70, -- Left fourth toenail at0.71, -- Right little toenail at0.72] -- Left little toenail } } } } CLUSTER[at0.85] occurrences matches {0..1} matches { -- Nail plate items cardinality matches {0..*; unordered} matches { ELEMENT[at0036] occurrences matches {0..1} matches { -- Colour of nail value matches { DV_TEXT matches {*} } } ELEMENT[at0051] occurrences matches {0..1} matches { -- Contour of nail value matches { DV_TEXT matches {*} } } ELEMENT[at0027] occurrences matches {0..1} matches { -- Surface of nail value matches { DV_TEXT matches {*} } } ELEMENT[at0.73] occurrences matches {0..1} matches { -- Thickness of nail value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } ELEMENT[at0034] occurrences matches {0..1} matches { -- Translucent value matches { DV_BOOLEAN matches { value matches {True, False} } } } 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 } } } } } } 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} } } } } } CLUSTER[at0.83] occurrences matches {0..1} matches { -- Nail integrity items cardinality matches {0..*; unordered} matches { ELEMENT[at0.84] occurrences matches {0..1} matches { -- Description value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } } } } } CLUSTER[at0.86] occurrences matches {0..1} matches { -- Nail bed items cardinality matches {0..*; unordered} matches { ELEMENT[at0.82] occurrences matches {0..1} matches { -- Pallor of Nail bed value matches { DV_BOOLEAN matches { value matches {True, False} } } } ELEMENT[at0.88] occurrences matches {0..1} matches { -- Subungual haematoma value matches { DV_BOOLEAN matches { value matches {True, False} } } } } } CLUSTER[at0.93] occurrences matches {0..1} matches { -- Description of other nail structures items cardinality matches {0..*; unordered} matches { ELEMENT[at0.96] occurrences matches {0..1} matches { -- Nail structures value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.97, -- Eponychium/cuticle at0.98, -- Paronychium at0.99, -- Hyponychium at0.100, -- Lunula at0.101] -- Nail fold } } } } ELEMENT[at0.95] occurrences matches {0..1} matches { -- Description value matches { DV_CODED_TEXT matches { defining_code matches {[local::]} } } } } } CLUSTER[at0.87] occurrences matches {0..1} matches { -- Nail Surrounds items cardinality matches {0..*; unordered} matches { ELEMENT[at0024] occurrences matches {0..1} matches { -- General Description value matches { DV_TEXT matches {*} } } } } CLUSTER[at0049] occurrences matches {0..1} matches { -- Detail items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/exam\.v1/} } } } } } } } ELEMENT[at0.74] occurrences matches {0..1} matches { -- Photograph value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 425, 426, 427, 428, 429] } } } } 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 = < ["at0.100"] = < description = <"The crescent shaped whitish area of the nail bed (when visible)"> text = <"Lunula"> > ["at0.101"] = < description = <"Fold of hard skin overlapping the base and sides of a fingernail or toenail."> text = <"Nail fold"> > ["at0.52"] = < description = <"*"> text = <"Identify Nail"> > ["at0.53"] = < description = <"*"> text = <"Right thumbnail"> > ["at0.54"] = < description = <"*"> text = <"Left Thumbnail"> > ["at0.55"] = < description = <"*"> text = <"Right index fingernail"> > ["at0.56"] = < description = <"*"> text = <"Left index fingernail"> > ["at0.57"] = < description = <"*"> text = <"Right middle fingernail"> > ["at0.58"] = < description = <"*"> text = <"Left middle fingernail"> > ["at0.59"] = < description = <"*"> text = <"Right ring fingernail"> > ["at0.60"] = < description = <"*"> text = <"Left ring fingernail"> > ["at0.61"] = < description = <"*"> text = <"Right little fingernail"> > ["at0.62"] = < description = <"*"> text = <"Left little fingernail"> > ["at0.63"] = < description = <"*"> text = <"Right great/first toenail"> > ["at0.64"] = < description = <"*"> text = <"Left great/first toenail"> > ["at0.65"] = < description = <"*"> text = <"Right second toenail"> > ["at0.66"] = < description = <"*"> text = <"Left second toenail"> > ["at0.67"] = < description = <"*"> text = <"Right third toenail"> > ["at0.68"] = < description = <"*"> text = <"Left third toenail"> > ["at0.69"] = < description = <"*"> text = <"Right fourth toenail"> > ["at0.70"] = < description = <"*"> text = <"Left fourth toenail"> > ["at0.71"] = < description = <"*"> text = <"Right little toenail"> > ["at0.72"] = < description = <"*"> text = <"Left little toenail"> > ["at0.73"] = < description = <"*"> text = <"Thickness of nail"> > ["at0.74"] = < description = <"*"> text = <"Photograph"> > ["at0.75"] = < description = <"*"> text = <"Clubbing"> > ["at0.76"] = < description = <"*"> text = <"Present"> > ["at0.77"] = < description = <"*"> text = <"Description"> > ["at0.78"] = < description = <"*"> text = <"Staging"> > ["at0.79"] = < description = <"*"> text = <"Loss of normal 160° angle at base of nail"> > ["at0.80"] = < description = <"*"> text = <"AP curvature increase"> > ["at0.81"] = < description = <"*"> text = <"new ordinal"> > ["at0.82"] = < description = <"*"> text = <"Pallor of Nail bed"> > ["at0.83"] = < description = <"Is the nail plate intact or damaged/breached by trauma etc"> text = <"Nail integrity"> > ["at0.84"] = < description = <"*"> text = <"Description"> > ["at0.85"] = < description = <"Findings about the nail plate - the hard and translucent portion of the nail, composed of keratin."> text = <"Nail plate"> > ["at0.86"] = < description = <"# nail bed is the adherent connective tissue that underlies the nail."> text = <"Nail bed"> > ["at0.87"] = < description = <"*"> text = <"Nail Surrounds"> > ["at0.88"] = < description = <"*"> text = <"Subungual haematoma"> > ["at0.89"] = < description = <"Details about clubbing of nails"> text = <"Clubbing"> > ["at0.90"] = < description = <"*"> text = <"Specific nail details"> > ["at0.91"] = < description = <"# eponychium or cuticle, is the fold of skin at the proximal end of the nail. "> text = <"Eponychium/Cuticle"> > ["at0.92"] = < description = <" "> text = <"Paronychium"> > ["at0.93"] = < description = <"*"> text = <"Description of other nail structures"> > ["at0.94"] = < description = <"# hyponychium is the attachment between the skin of the finger or toe and the distal end of the nail. "> text = <"Hyponychium"> > ["at0.95"] = < description = <"# lunula is the crescent shaped whitish area of the nail bed (when visible)"> text = <"Description"> > ["at0.96"] = < description = <"*"> text = <"Nail structures"> > ["at0.97"] = < description = <"The fold of skin at the proximal end of the nail."> text = <"Eponychium/cuticle"> > ["at0.98"] = < description = <"The fold of skin on the sides of the nail."> text = <"Paronychium"> > ["at0.99"] = < description = <"The attachment between the skin of the finger or toe and the distal end of the nail."> text = <"Hyponychium"> > ["at0000"] = < description = <"The findings on physical examination by inspection"> text = <"Inspection"> > ["at0000.1"] = < description = <"Findings on inspection of nails"> text = <"Inspection of nails"> > ["at0001"] = < description = <"An optional group of statements about the normality of the inspection"> text = <"Normal statements"> > ["at0002"] = < description = <"A specific statement about the normality of inspection"> text = <"Normal statement"> > ["at0005"] = < description = <"The location of any findings"> text = <"Location of findings"> > ["at0006"] = < description = <"Specific findings on inspection"> text = <"Findings"> > ["at0018"] = < description = <"The shape or distribution of the object inspected"> text = <"Shape or distribution"> > ["at0019"] = < description = <"Description of the "> text = <"Description"> > ["at0020"] = < description = <"Whether the distribution is symmetrical"> text = <"Symmetrical"> > ["at0022"] = < description = <"Description of the location of the findings"> text = <"Identify nail"> > ["at0024"] = < description = <"Description of immediate surrounds to object eg skin nailbed and nailfold"> text = <"General Description"> > ["at0027"] = < description = <"A description of the surface"> text = <"Surface of nail"> > ["at0028"] = < description = <"Findings about the edge of the object under inspection"> text = <"Edge"> > ["at0029"] = < description = <"The nature of the edge of the object of examination"> text = <"Definition"> > ["at0030"] = < description = <"The edge is clearly defined"> text = <"Well defined"> > ["at0031"] = < description = <"The edge is defined but less clear in places"> text = <"Moderately defined"> > ["at0032"] = < description = <"The edge is not defined clearly in many places"> text = <"Poorly defined"> > ["at0033"] = < description = <"Description of the edge or border of the object of inspection"> text = <"Description"> > ["at0034"] = < description = <"Is the object of inspection translucent?"> text = <"Translucent"> > ["at0036"] = < description = <"The colour of the object under inspection"> text = <"Colour of nail"> > ["at0048"] = < description = <"Clinical description of the findings on inspection"> text = <"Clinical Description"> > ["at0049"] = < description = <"Detailed examination of a finding on inspection"> text = <"Detail"> > ["at0050"] = < description = <"A drawing of the findings on inspection"> text = <"Drawing"> > ["at0051"] = < description = <"The contour of the object of inspection"> text = <"Contour of nail"> > > > >