archetype (adl_version=1.4) openEHR-EHR-CLUSTER.inspection-skin.v1draft specialize openEHR-EHR-CLUSTER.inspection.v1draft concept [at0000.1] -- Inspection of skin language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Ocean Informatics"> ["date"] = <"10/04/2007"> ["email"] = <"heather.leslie@oceaninformatics.biz"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording the findings on inspection of the skin"> use = <"For use with the exam clusters for recording findings on inspection"> keywords = <"inspect", "visual", "skin"> misuse = <"Should only be used in the exam observation"> > > lifecycle_state = <"Initial"> other_contributors = <> definition CLUSTER[at0000.1] matches { -- Inspection of skin 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 {*} } } } } ELEMENT[at0048] occurrences matches {0..1} matches { -- Clinical Description value matches { DV_TEXT matches {*} } } CLUSTER[at0006] occurrences matches {0..*} matches { -- Findings items cardinality matches {0..*; unordered} matches { ELEMENT[at0.52] occurrences matches {0..1} matches { -- Method value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.53, -- Direct visualisation at0.54, -- Wood's lamp at0.55] -- Dermatoscope } } } } 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[at0051] occurrences matches {0..1} matches { -- Contour value matches { DV_TEXT matches {*} } } ELEMENT[at0027] occurrences matches {0..1} matches { -- Surface value matches { DV_TEXT matches {*} } } ELEMENT[at0.56] occurrences matches {0..1} matches { -- Thickness value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.57, -- Thickened at0.58, -- Normal at0.59] -- Thinned/Atrophic } } } } ELEMENT[at0024] occurrences matches {0..1} matches { -- Surrounds value matches { DV_TEXT matches {*} } } ELEMENT[at0.60] occurrences matches {0..1} matches { -- Pigmentation 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} } } } 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[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"] = < description = <"Record of findings on inspection using a specific method"> text = <"Method"> > ["at0.53"] = < description = <"Macroscopic; By eye"> text = <"Direct visualisation"> > ["at0.54"] = < description = <"*"> text = <"Wood's lamp"> > ["at0.55"] = < description = <"*"> text = <"Dermatoscope"> > ["at0.56"] = < description = <"Thickness of skin"> text = <"Thickness"> > ["at0.57"] = < description = <"*"> text = <"Thickened"> > ["at0.58"] = < description = <"*"> text = <"Normal"> > ["at0.59"] = < description = <"*"> text = <"Thinned/Atrophic"> > ["at0.60"] = < description = <"Pigmentation of skin"> text = <"Pigmentation"> > ["at0000"] = < description = <"The findings on physical examination by inspection"> text = <"Inspection"> > ["at0000.1"] = < description = <"The findings on inspection of the skin"> text = <"Inspection of skin"> > ["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"> > ["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 = <"Description"> > ["at0024"] = < description = <"Description of immediate surrounds to object"> text = <"Surrounds"> > ["at0027"] = < description = <"A description of the surface"> text = <"Surface"> > ["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 description"> > ["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"> > > > >