> > 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
> 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 Thanks that does help, the use case is building a form to represent this example ========================================================================== Ms. Jane Doe was seen at our clinic as she was complaining of severe abdominal pain and cramps with loss of appetite, and frequent stool motions about 6 times a day, vomiting and nausea and sever weakness and malaise. The condition started yesterday by sudden onset and progressive course her examination revealed the following:- General examination:- On examination she looked weakened and her vital data was as following: Pulse: 80 beats/min B.P: 120/70 mmgh Temp: 38.5 C R.R: 16 Heart examination: Clinically free & unremarkable. Chest examination: Clinically free & unremarkable. Clinical findings: Blah blah =========================================================================== So I then have the mapping Story: 1st paragraph Clinical Description: On examination she looked weakened and her vital data was as following: Vitals: Pulse: 80 beats/min B.P: 120/70 mmgh Temp: 38.5 C R.R: 16 Normal findings: Heart examination: Clinically free & unremarkable. Normal findings: Chest examination: Clinically free & unremarkable. Clinical Description: Blah blah I think that is acceptable. thanks! Greg
