| |
 Normal statements, A group of statements about the normality of the palpation. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
 Normal statement |
A specific statement of normality | Coded text
| optional, repeating
0..* |
Normal
Probably normal
No abnormality detected
Soft
No tenderness
No masses
No foreign bodies
No hernias |
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
| Clinical description |
Textural statement of the findings on palpation | Text
| optional
0..1 |
Free or coded text |
| Findings, Group of findings. Cluster (0..1) optional |
| |
| Tenderness, A group of statements about a tenderness finding. Cluster (0..*) optional, repeating |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Depth of palpation |
The depth of palpation | Coded text
| optional
0..1 |
Superficial
Deep |
| Degree |
The amount or degree of tenderness found on palpation | Coded text
| optional
0..1 |
absent
mild
moderate
marked
extreme |
| Category |
The type of tenderness found on palpation | Coded text
| optional
0..1 |
Superficial tenderness
Deep tenderness
Rebound tenderness
Tenderness
Rigidity |
| Body site |
The region, site or organ that is the object of localised palpation | Text
| mandatory
1..1 |
Free or coded text |
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
| Temperature |
The temperature on palpation | Coded text
| optional
0..1 |
Cold
Cool
Normal
Warm
Hot |
| Guarding, Tensing of underlying muscles on palpation. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Degree |
The degree of guarding | Coded text
| optional
0..1 |
Not present
Mild
Moderate
Gross |
| Nature |
The nature of the guarding | Coded text
| optional
0..1 |
Voluntary
Involuntary
Uncertain |
|
|
|
| Localised palpation, Palpation of a localised area. Cluster (0..*) optional, repeating |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Body site |
The region, site or organ that is the object of localised palpation | Text
| mandatory
1..1 |
Free or coded text |
 Cough impulse |
Presence of a cough impulse felt on palpation | Boolean
| optional
0..1 |
True |
Slot |
Type |
Occurrences |
Constraints |
 |
CLUSTER |
0..* |
Include entries
Exclude entries:
|
|
|
| Surface/Border, Findings related to the surface or border of the object of palpation. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Site description |
Details of the location of the surface or border palpated | Text
| optional
0..1 |
Free or coded text |
| Consistency |
The consistency of the surface or border of the object of palpation | Coded text
| optional
0..1 |
Hard/Rigid
Firm
Soft
Boggy
Indents |
| Features |
Features of the surface or border | Coded text
| optional, repeating
0..* |
Smooth
Craggy
Irregular
Nodular |
|
|
|
| Detail, Detailed examination of things found on palpation. Cluster (0..1) optional |
| |
Slot |
Type |
Occurrences |
Constraints |
|
CLUSTER |
0..* |
Include entries
Exclude entries:
|
|
|
|
|
|
|
|
|
|
Generated by the Ocean HTML generator: 13/04/2007
|
