Hi Greg,

The clinical description element, which is replicated in the inspection,
palpation and ausculation cluster archetypes should be used to carry any
free text.

I'm not sure I can see the semantic difference between 'clinical
description' and
'findings/findings description' although I agree that the latter is slightly
tidier from a human readability perspective.

Do you have a particular use case in mind?

Regards,

Ian

Dr Ian McNicoll
office / fax  +44(0)141 560 4657
mobile +44 (0)775 209 7859
skype ianmcnicoll
ian at mcmi.co.uk

Clinical Analyst - Ocean Informatics ian.mcnicoll at oceaninformatics.com

Consultant - IRIS GP Accounts ian at gpacc.co.uk

Member of BCS Primary Health Care Specialist Group ? www.phcsg.org


2008/10/23 Greg Caulton <caultonpos at gmail.com>

> I have an Archetype question on openEHR-EHR-CLUSTER.exam.v1
>
> The archetype appears to be designed such that the findings can only
> be expressed with a limited set of attributes - color, location,
> shape, etc.  - things specific to the archetypes Inspection,
> Auscultation, Percussion and Palpation
>
> This is the hierarchy (or part of it)
>
> exam
>   -- normal statements
>   ----- normal statement
>   -- clinical description
>   -- findings
>   ----- detail
>   --------- exam-generic
>
>
> exam-generic
>   -- object
>   -- normal statements
>   ----- normal statement
>   -- clinical description
>   -- findings
>   ----- inspection
>   ----- auscultation
>   ----- percussion
>   ----- palpation
>   --------- detail
>   ------------- exam-generic
>
>
> inspection
> -- findings
> ----- color description
> ----- location
> ----- shape or distribution
> ----- edge
> ----- translucent
> ----- detail
> --------- exam
>
>
> What I was hoping to find was a free text clinical description under
> findings that could be used in lieu of the specialized archetypes
>
> i.e.
>
>   -- normal statements
>   ----- normal statement
>   -- clinical description
>   -- findings
>   ----- findings description     <<<<<------------------------
>   ----- detail
>   --------- exam-generic
>
> thanks!
>
> Greg
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical at openehr.org
> http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical
>
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