Auscultation: Cluster

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Comments to Heather Leslie (Ocean)
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Concept

Archetype Id

Structure

Findings on Auscultation Id: openEHR-EHR-CLUSTER.auscultation.v1
Reference model: EHR
ADL, (ADL)

Cluster

 

Element

 

Auscultation, Findings on Auscultation.       Cluster (1..1) mandatory
 
Normal Statements, A group of statements about the normality of auscultation.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Normal Statement Statements about the normality of the auscultationCoded text
optional, repeating
0..*
No murmur
No bruit
Normal bowel sounds
No abnormality detected

Concept

Description

Type

Cardinality

Values

Clinical Description Detailed clinical description of the findings on auscultationText
optional
0..1
Free or coded text
Findings, Findings on auscultation.       Cluster (0..1) optional
 
Bowel sounds, Group of findings about auscultation of the bowel.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Specific Findings Specific auscultatory findings related to examination of the bowelsCoded text
optional, repeating
0..*
Absent bowel sounds
Decreased bowel sounds
Increased bowel sounds
Tinkling bowel sounds
Clinical Description Detailed clinical description of the findings on auscultationText
optional
0..1
Free or coded text

Vessel bruit, Group of findings about auscultation of a major blood vessel.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Vessel name The name of the vessel to which is being listenedText
mandatory
1..1
Free or coded text
Maximal Location Site where finding is heard maximallyText
optional
0..1
Free or coded text
Description Description of the bruitText
optional
0..1
Free or coded text

Other sounds, Recording of sounds of a different nature.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Description Description of other soundsText
mandatory
1..1
Free or coded text
Maximal Location Site where finding is heard maximallyText
optional
0..1
Free or coded text

Localised auscultation, Auscultation in a particular site.       Cluster (0..*) optional, repeating
 

Concept

Description

Type

Cardinality

Values

Site or region The site of the localised findingsText
mandatory
1..1
Free or coded text

Slot

Type

Occurrences

Constraints

CLUSTER 0..* Include entries




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