Norwegian openEHR Repository
Name
Physical examination of a hip joint
Description
Findings observed during the physical examination of a hip joint.
Keywords
articulatio coxae osteoarthritis
Purpose
To record the findings observed during the physical examination of a hip joint.
Use
Use to record the observed findings during the physical examination of a hip joint.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the "Procedure detail" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate.
Interpretation of the findings, for example 'No abnormality detected', can be recorded using the 'Clinical interpretation' data element.

The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed.

The intended scope for this archetype is to eventually record all detailed findings on physical examination of the hip joint. It is anticipated that further data elements may be added as requirements are identified and confirmed.

Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
Misuse
Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.

Not to be used for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose.
References
Avgrenet fra: Examination findings, Published archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2022-03-29]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.6153
Muscle Strength Testing [Internet]. Physiopedia [cited: 2023-04-13]. Available from: https://www.physio-pedia.com/Muscle_Strength_Testing.
Hip Examination [Internet]. Pysiopedia [cited: 2023-04-13]. Available from https://www.physio-pedia.com/Hip_Examination.
Archetype Id
openEHR-EHR-CLUSTER.exam-hip_joint.v0
Copyright
© Nasjonal IKT HF, openEHR Foundation
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
Original Author
Hanne Marte Bårholm
Helse Vest IKT AS
Date Originally Authored
2023-03-15
Language Details
German
Nina Schewe
Medizinische Hochschule Hannover
Swedish
Erik Sundvall
Region Östergötland + Linköping University
Norwegian Bokmal
Hanne Marte Sandal Bårholm, John Tore Valand
Helse Vest IKT
Portuguese (Brazil)
Adriana Kitajima
Hospital Alemão Oswaldo Cruz - HAOC
Name Card Type Description
System or structure examined
1..1 DV_CODED_TEXT Identification of the examined body system or anatomical structure.
Comment
Coding of the system or structure examined with a terminology is preferred, where possible.
Constraint for DV_CODED_TEXT
  • Left hip joint
  • Right hip joint
Body site
0..1 DV_TEXT Identification of the area of the body under examination.
Comment
If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant.
Structured body site
0..* Slot (Cluster) A structured description of the area of the body under examination.
Comment
If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant.
Slot
Slot
Clinical description
0..1 DV_TEXT Narrative description of the overall findings observed during the physical examination.
Examination findings
0..* Slot (Cluster) Structured details about the physical examination findings.
Slot
Slot
Multimedia representation
0..* Slot (Cluster) Digital image, video or diagram representing the physical examination findings.
Slot
Slot
Clinical interpretation
0..* DV_TEXT Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
Comment
For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible.
Comment
0..1 DV_TEXT Additional narrative about the physical examination findings, not captured in other fields.
Examination not done
0..* Slot (Cluster) Details to explicitly record that this examination was not performed.
Slot
Slot
archetype (adl_version=1.4; uid=dd4462ff-3ec5-447e-b94e-0b834b7231d5)
	openEHR-EHR-CLUSTER.exam-hip_joint.v0
specialise
	openEHR-EHR-CLUSTER.exam.v2

concept
	[at0000.1]	-- Physical examination of a hip joint
language
	original_language = <[ISO_639-1::en]>
	translations = <
		["de"] = <
			language = <[ISO_639-1::de]>
			author = <
				["name"] = <"Nina Schewe">
				["organisation"] = <"Medizinische Hochschule Hannover">
				["email"] = <"schewe.nina@mh-hannover.de">
			>
		>
		["sv"] = <
			language = <[ISO_639-1::sv]>
			author = <
				["name"] = <"Erik Sundvall">
				["organisation"] = <"Region Östergötland + Linköping University">
				["email"] = <"erik.sundvall@regionostergotland.se">
			>
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			author = <
				["name"] = <"Hanne Marte Sandal Bårholm, John Tore Valand">
				["organisation"] = <"Helse Vest IKT">
				["email"] = <"hanne.marte.sandal.barholm@helse-vest-ikt.no, john.tore.valand@helse-vest-ikt.no">
			>
		>
		["pt-br"] = <
			language = <[ISO_639-1::pt-br]>
			author = <
				["name"] = <"Adriana Kitajima">
				["organisation"] = <"Hospital Alemão Oswaldo Cruz - HAOC">
				["email"] = <"adrianakitajima@gmail.com">
			>
		>
	>
description
	original_author = <
		["name"] = <"Hanne Marte Bårholm">
		["organisation"] = <"Helse Vest IKT AS">
		["email"] = <"hanne.marte.sandal.barholm@helse-vest-ikt.no">
		["date"] = <"2023-03-15">
	>
	details = <
		["de"] = <
			language = <[ISO_639-1::de]>
			purpose = <"*To record the findings observed during the physical examination of a body system or anatomical structure. (en)">
			use = <"*Use to record the observed findings during the physical examination of a body system or anatomical structure.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the \"Procedure detail\" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Specialisations of this archetype can be used to record examination findings for identified body systems or anatomical structures. If there is no appropriate specialisation available, use this archetype and identify the system or structure being examined using the 'System or structure examined' data element and the location on the body using the 'Body site' data element or the 'Structured body site' SLOT.

Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element.

Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings.

The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed.

Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. (en)">
			keywords = <"*articulatio coxae, arthrosis (en)", ...>
			misuse = <"*Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.

Not to be used for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose. (en)">
			copyright = <"© Nasjonal IKT HF">
		>
		["sv"] = <
			language = <[ISO_639-1::sv]>
			purpose = <"*To record the findings observed during the physical examination of a body system or anatomical structure. (en)">
			use = <"*Use to record the observed findings during the physical examination of a body system or anatomical structure.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the \"Procedure detail\" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Specialisations of this archetype can be used to record examination findings for identified body systems or anatomical structures. If there is no appropriate specialisation available, use this archetype and identify the system or structure being examined using the 'System or structure examined' data element and the location on the body using the 'Body site' data element or the 'Structured body site' SLOT.

Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element.

Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings.

The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed.

Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. (en)">
			keywords = <"*articulatio coxae, arthrosis (en)", ...>
			misuse = <"*Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.

Not to be used for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose. (en)">
			copyright = <"© Nasjonal IKT HF">
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			purpose = <"For å registrere funn ved fysisk undersøkelse av et hofteledd.">
			use = <"Brukes for å registrere funn ved fysisk undersøkelse av et hofteledd.

Denne arketypen har vært designet spesifikt for å kunne brukes i SLOT'et \"Undersøkelsesdetaljer\" i arketypen OBSERVATION.exam (Funn ved fysisk undersøkelse) eller SLOT'et \"Prosedyredetaljer\" i arketypen ACTION.procedure (Prosedyre), men kan også bli brukt i andre ENTRY- eller CLUSTER-arketyper der det er klinisk passende.

Tolkning av funn kan bli registrert i dataelementet \"Fortolkning\", for eksempel \"Uten anmerkning\".

Arketypen CLUSTER.exclusion_exam (Eksklusjon av en undersøkelse) kan nøstes inn i SLOT'et \"Undersøkelse ikke utført\" for å registrere begrunnelse eller detaljer om hvorfor undersøkelsen ikke ble utført.

Det tiltenkte omfanget for denne arketypen er til slutt å kunne registrere alle detaljerte funn ved fysisk undersøkelse av et hofteledd. Det er forventet at flere dataelementer kan bli lagt til når krav til slike er identifisert og bekreftet.

Brukes for å legge til fritekstlige beskrivelser av undersøkelsesfunn fra eksisterende eller historiske journalsystemer til arketypeformat ved å benytte dataelementet \"Klinisk beskrivelse\".">
			keywords = <"articulatio coxae, artrose, hofteleddsdysplasi", ...>
			misuse = <"Skal ikke brukes til å ta opp anamnese - bruk da spesifikke OBSERVATION og CLUSTER arketyper. For eksempel OBSERVATION.story og CLUSTER.symptom_sign.

Skal ikke brukes for å registrere funn ved bildeundersøkelse - bruk en arketype innen gruppen av CLUSTER.imaging_exam (Bildeundersøkelse) for dette formålet.">
			copyright = <"© Nasjonal IKT HF, openEHR Foundation">
		>
		["pt-br"] = <
			language = <[ISO_639-1::pt-br]>
			purpose = <"*To record the findings observed during the physical examination of a body system or anatomical structure. (en)">
			use = <"*Use to record the observed findings during the physical examination of a body system or anatomical structure.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the \"Procedure detail\" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Specialisations of this archetype can be used to record examination findings for identified body systems or anatomical structures. If there is no appropriate specialisation available, use this archetype and identify the system or structure being examined using the 'System or structure examined' data element and the location on the body using the 'Body site' data element or the 'Structured body site' SLOT.

Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element.

Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings.

The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed.

Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. (en)">
			keywords = <"*articulatio coxae, arthrosis (en)", ...>
			misuse = <"*Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.

Not to be used for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose. (en)">
			copyright = <"© Nasjonal IKT HF">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To record the findings observed during the physical examination of a hip joint.">
			use = <"Use to record the observed findings during the physical examination of a hip joint.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the \"Procedure detail\" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. 
Interpretation of the findings, for example 'No abnormality detected', can be recorded using the 'Clinical interpretation' data element.

The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed.

The intended scope for this archetype is to eventually record all detailed findings on physical examination of the hip joint. It is anticipated that further data elements may be added as requirements are identified and confirmed.

Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.">
			keywords = <"articulatio coxae, osteoarthritis", ...>
			misuse = <"Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.

Not to be used for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose.">
			copyright = <"© Nasjonal IKT HF, openEHR Foundation">
		>
	>
	lifecycle_state = <"in_development">
	other_contributors = <"Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)", "Silje Ljosland Bakke, Helse Vest IKT AS, Norway (Nasjonal IKT redaktør)", "Ivar Berge, Oslo Universitetssykehus, Norway", "SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India", "Heather Grain, Llewelyn Grain Informatics, Australia", "Ronald Krawec, Alberta Health Services, Canada", "Jörgen Kuylenstierna, eWeave AB, Sweden", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Michael Lutz, BITsoft, Germany", "Hanne Marte Bårholm, Helse Vest IKT AS", "Svenne Naumann, Finnmarkssykehuset, Norway", "Mikael Nyström, Cambio Healthcare Systems AB, Sweden", "Norwegian Review Summary, Norwegian Public Hospitals, Norway", "Stein Arne Rimehaug, Sunnaas sykehus, Norway", "Terje Sagmyr, Helse Vest IKT, Norway", "Bodil Salvesen, Barneklinikken Haukeland Universitetssykehus, Norway", "Natalia Strauch, Medizinische Hochschule Hannover, Germany", "Kanthan Theivendran, NHS, United Kingdom", "Anders Thurin, VGR, Sweden", "John Tore Valand, Helse Vest IKT, Norway (Nasjonal IKT redaktør)">
	other_details = <
		["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.">
		["custodian_organisation"] = <"openEHR Foundation">
		["references"] = <"Avgrenet fra: Examination findings, Published archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2022-03-29]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.6153
	
Muscle Strength Testing [Internet]. Physiopedia [cited: 2023-04-13]. Available from: https://www.physio-pedia.com/Muscle_Strength_Testing.

Hip Examination [Internet]. Pysiopedia [cited: 2023-04-13]. Available from https://www.physio-pedia.com/Hip_Examination.">
		["current_contact"] = <"Heather Leslie, Atomica Informatics, Australia<heather.leslie@atomicainformatics.com>">
		["original_namespace"] = <"org.openehr">
		["original_publisher"] = <"openEHR Foundation">
		["custodian_namespace"] = <"org.openehr">
		["MD5-CAM-1.0.1"] = <"C2D0313420E6DFF8593236709D0B3AE6">
		["build_uid"] = <"283e2d50-42c7-43ae-bd60-039593f601ff">
		["ip_acknowledgements"] = <"This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.">
		["revision"] = <"0.0.1-alpha">
	>

definition
	CLUSTER[at0000.1] matches {    -- Physical examination of a hip joint
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0001.1] matches {    -- System or structure examined
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.1,    -- Left hip joint
							at0.2]    -- Right hip joint
						}
					}
				}
			}
			ELEMENT[at0012] occurrences matches {0..1} matches {    -- Body site
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0011] occurrences matches {0..*} matches {    -- Structured body site
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v2/}
			}
			ELEMENT[at0003] occurrences matches {0..1} matches {    -- Clinical description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0004] occurrences matches {0..*} matches {    -- Examination findings
				include
					archetype_id/value matches {/.*/}
			}
			allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches {    -- Multimedia representation
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.media_file(-[a-zA-Z0-9_]+)*\.v1/}
			}
			ELEMENT[at0006] occurrences matches {0..*} matches {    -- Clinical interpretation
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0007] occurrences matches {0..1} matches {    -- Comment
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches {    -- Examination not done
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/}
			}
		}
	}



ontology
	terminologies_available = <"SNOMED-CT", ...>
	term_definitions = <
		["en"] = <
			items = <
				["at0.1"] = <
					text = <"Left hip joint">
					description = <"">
				>
				["at0.2"] = <
					text = <"Right hip joint">
					description = <"">
				>
				["at0000"] = <
					text = <"Examination findings">
					description = <"Findings observed during the physical examination of a body system or anatomical structure.">
				>
				["at0000.1"] = <
					text = <"Physical examination of a hip joint">
					description = <"Findings observed during the physical examination of a hip joint.">
				>
				["at0001"] = <
					text = <"System or structure examined">
					description = <"Identification of the examined body system or anatomical structure.">
					comment = <"Coding of the system or structure examined with a terminology is preferred, where possible.">
				>
				["at0001.1"] = <
					text = <"System or structure examined">
					description = <"Identification of the examined body system or anatomical structure.">
					comment = <"Coding of the system or structure examined with a terminology is preferred, where possible.">
				>
				["at0003"] = <
					text = <"Clinical description">
					description = <"Narrative description of the overall findings observed during the physical examination.">
				>
				["at0004"] = <
					text = <"Examination findings">
					description = <"Structured details about the physical examination findings.">
				>
				["at0005"] = <
					text = <"Multimedia representation">
					description = <"Digital image, video or diagram representing the physical examination findings.">
				>
				["at0006"] = <
					text = <"Clinical interpretation">
					description = <"Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.">
					comment = <"For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible.">
				>
				["at0007"] = <
					text = <"Comment">
					description = <"Additional narrative about the physical examination findings, not captured in other fields.">
				>
				["at0008"] = <
					text = <"Examination not done">
					description = <"Details to explicitly record that this examination was not performed.">
				>
				["at0011"] = <
					text = <"Structured body site">
					description = <"A structured description of the area of the body under examination.">
					comment = <"If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant.">
				>
				["at0012"] = <
					text = <"Body site">
					description = <"Identification of the area of the body under examination.">
					comment = <"If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant.">
				>
			>
		>
		["nb"] = <
			items = <
				["at0.1"] = <
					text = <"Venstre hofteledd">
					description = <"">
				>
				["at0.2"] = <
					text = <"Høyre hofteledd">
					description = <"">
				>
				["at0000"] = <
					text = <"Undersøkelsesfunn">
					description = <"Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur.">
				>
				["at0000.1"] = <
					text = <"Fysisk undersøkelse av et hofteledd">
					description = <"Funn ved fysisk undersøkelse av et hofteledd.">
				>
				["at0001"] = <
					text = <"Undersøkt organsystem eller struktur">
					description = <"Identifisering av det undersøkte organsystemet eller den anatomiske strukturen.">
					comment = <"Det anbefales å kode organsystem eller den anatomiske strukturen med en terminologi dersom mulig.">
				>
				["at0001.1"] = <
					text = <"Undersøkt organsystem eller struktur">
					description = <"Identifisering av det undersøkte organsystemet eller den anatomiske strukturen.">
					comment = <"Det anbefales å kode organsystem eller den anatomiske strukturen med en terminologi dersom mulig.">
				>
				["at0003"] = <
					text = <"Klinisk beskrivelse">
					description = <"Fritekstbeskrivelse av de overordnede funnene ved den fysiske undersøkelsen.">
				>
				["at0004"] = <
					text = <"Spesifikke funn">
					description = <"Ytterligere strukturerte detaljer om undersøkelsesfunnene.">
				>
				["at0005"] = <
					text = <"Multimediarepresentasjon">
					description = <"Digitale bilder, video eller diagram som representerer undersøkelsesfunnene.">
				>
				["at0006"] = <
					text = <"Fortolkning">
					description = <"Enkelt ord, setning, frase eller kort beskrivelse som representerer den kliniske betydning og viktigheten av funnene ved den fysiske undersøkelsen.">
					comment = <"For eksempel \"Uten anmerkning\" eller \"Moderat inflammasjon\". Det anbefales å kode \"Fortolkning\" med en terminologi dersom mulig.">
				>
				["at0007"] = <
					text = <"Kommentar">
					description = <"Ytterligere fritekst om funn ved undersøkelsen, som ikke dekkes av andre elementer.">
				>
				["at0008"] = <
					text = <"Undersøkelse ikke utført">
					description = <"Detaljer for å eksplisitt registrere at denne undersøkelsen ikke ble utført.">
				>
				["at0011"] = <
					text = <"Strukturert anatomisk lokalisasjon">
					description = <"Angivelse av en strukturert anatomisk lokalisering av det undersøkte organsystemet eller den anatomiske strukturen.">
					comment = <"Hvis anatomisk lokalisasjon er entydig identifisert i elementet \"Undersøkt organsystem eller struktur\" er dette SLOT'et ikke nødvendig å benytte.">
				>
				["at0012"] = <
					text = <"Anatomisk lokalisasjon">
					description = <"Identifisering av et enkelt fysisk sted enten på eller i menneskekroppen.">
					comment = <"Dersom den anatomiske lokaliseringen allerede er identifisert i elementet \"Undersøkt organsystem eller struktur\" er dette dataelementet overflødig.">
				>
			>
		>
		["pt-br"] = <
			items = <
				["at0.1"] = <
					text = <"*Left hip joint (en)">
					description = <"">
				>
				["at0.2"] = <
					text = <"Right hip joint">
					description = <"">
				>
				["at0000.1"] = <
					text = <"*Physical examination of a hip joint (en)">
					description = <"Constatações observadas durante o exame físico de um sistema corporal ou estrutura anatômica.">
				>
				["at0001.1"] = <
					text = <"Sistema ou estrutura examinada">
					description = <"Identificação do sistema do corpo examinado ou da estrutura anatômica.">
					comment = <"A codificação do sistema ou estrutura examinada com uma terminologia é preferível, sempre que possível.">
				>
				["at0000"] = <
					text = <"Resultados do exame">
					description = <"Constatações observadas durante o exame físico de um sistema corporal ou estrutura anatômica.">
				>
				["at0001"] = <
					text = <"Sistema ou estrutura examinada">
					description = <"Identificação do sistema do corpo examinado ou da estrutura anatômica.">
					comment = <"A codificação do sistema ou estrutura examinada com uma terminologia é preferível, sempre que possível.">
				>
				["at0003"] = <
					text = <"Descrição clínica">
					description = <"Descrição narrativa dos achados gerais observados durante o exame físico.">
				>
				["at0004"] = <
					text = <"Resultados do exame">
					description = <"Detalhes estruturados sobre os resultados do exame físico.">
				>
				["at0005"] = <
					text = <"Representação multimídia">
					description = <"Imagem digital, vídeo ou diagrama representando os achados do exame físico.">
				>
				["at0006"] = <
					text = <"Interpretação clínica">
					description = <"Palavra, frase ou breve descrição que represente o significado clínico e o significado dos resultados do exame físico.">
					comment = <"*For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. (en)">
				>
				["at0007"] = <
					text = <"Comentário">
					description = <"Narrativa adicional sobre os achados do exame físico, não capturados em outros campos.">
				>
				["at0008"] = <
					text = <"Exame não realizado">
					description = <"Detalhes para registrar explicitamente que esse exame não foi realizado.">
				>
				["at0011"] = <
					text = <"Local do corpo estruturado">
					description = <"Uma descrição estruturada da área do corpo em exame.">
					comment = <"Se o local do corpo tiver sido totalmente identificado no elemento de dados 'Sistema ou estrutura examinada' ou 'Local do corpo', esse SLOT se tornará redundante.">
				>
				["at0012"] = <
					text = <"Local do corpo">
					description = <"Identificação da área do corpo em exame.">
					comment = <"Se o local do corpo foi totalmente identificado no elemento de dados 'Sistema ou estrutura examinada', esse elemento de dados se torna redundante.">
				>
			>
		>
		["de"] = <
			items = <
				["at0.1"] = <
					text = <"*Left hip joint (en)">
					description = <"">
				>
				["at0.2"] = <
					text = <"Right hip joint">
					description = <"">
				>
				["at0000.1"] = <
					text = <"*Physical examination of a hip joint (en)">
					description = <"Während der körperlichen Untersuchung eines Körpersystems oder einer anatomischen Struktur beobachtete Befunde.">
				>
				["at0001.1"] = <
					text = <"Untersuchtes System oder untersuchte Struktur">
					description = <"Identifizierung des untersuchten Körpersystems oder der anatomischen Struktur.">
					comment = <"Wenn möglich wird die Kodierung des untersuchten Systems oder der untersuchten Struktur mit einer Terminologie bevorzugt.">
				>
				["at0000"] = <
					text = <"Untersuchungsergebnisse">
					description = <"Während der körperlichen Untersuchung eines Körpersystems oder einer anatomischen Struktur beobachtete Befunde.">
				>
				["at0001"] = <
					text = <"Untersuchtes System oder untersuchte Struktur">
					description = <"Identifizierung des untersuchten Körpersystems oder der anatomischen Struktur.">
					comment = <"Wenn möglich wird die Kodierung des untersuchten Systems oder der untersuchten Struktur mit einer Terminologie bevorzugt.">
				>
				["at0003"] = <
					text = <"Klinische Beschreibung">
					description = <"Beschreibung der bei der körperlichen Untersuchung beobachteten Gesamtbefunde.">
				>
				["at0004"] = <
					text = <"Untersuchungsergebnisse">
					description = <"Strukturierte Angaben zu den Ergebnissen der körperlichen Untersuchung.">
				>
				["at0005"] = <
					text = <"Multimediale Darstellung">
					description = <"Digitales Bild, Video oder Diagramm, das die Ergebnisse der körperlichen Untersuchung darstellt.">
				>
				["at0006"] = <
					text = <"Klinische Interpretation">
					description = <"Ein einzelnes Wort, eine Phrase oder eine kurze Beschreibung, die die klinische Bedeutung und Wichtigkeit der Untersuchungsergebnisse darstellt.">
					comment = <"*For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. (en)">
				>
				["at0007"] = <
					text = <"Kommentar">
					description = <"Zusätzliche Beschreibung der Ergebnisse der körperlichen Untersuchung, die in anderen Bereichen nicht erfasst werden konnten.">
				>
				["at0008"] = <
					text = <"Nicht durchgeführte Untersuchung">
					description = <"Eine Aussage die ausdrücklich erfasst, dass die Untersuchung nicht durchgeführt wurde.">
				>
				["at0011"] = <
					text = <"Strukturierte Körperstelle">
					description = <"Eine strukturierte Beschreibung des zu untersuchenden Körperbereichs.">
					comment = <"Wenn die Körperstelle im Datenelement \"Untersuchtes System oder untersuchte Struktur\" oder im Datenelement \"Körperstelle\" vollständig identifiziert wurde, wird die Verwendung dieses SLOT überflüssig.">
				>
				["at0012"] = <
					text = <"Körperstelle">
					description = <"Identifizierung des Untersuchungsbereichs.">
					comment = <"Wenn die Körperstelle im Datenelement \"Untersuchtes System oder untersuchte Struktur\" vollständig identifiziert wurde, wird dieses Datenelement überflüssig.">
				>
			>
		>
		["sv"] = <
			items = <
				["at0.1"] = <
					text = <"*Left hip joint (en)">
					description = <"">
				>
				["at0.2"] = <
					text = <"Right hip joint">
					description = <"">
				>
				["at0000.1"] = <
					text = <"*Physical examination of a hip joint (en)">
					description = <"Observerade fynd vid fysisk undersökning av system i kroppen, eller av anatomisk struktur">
				>
				["at0001.1"] = <
					text = <"System eller struktur som undersökts">
					description = <"Identifiering av systemet eller strukturen som undersökts.">
					comment = <"Om möjligt, koda systemet eller strukturen med hjälp av ett terminologisystem.">
				>
				["at0000"] = <
					text = <"Fynd vid undersökning">
					description = <"Observerade fynd vid fysisk undersökning av system i kroppen, eller av anatomisk struktur">
				>
				["at0001"] = <
					text = <"System eller struktur som undersökts">
					description = <"Identifiering av systemet eller strukturen som undersökts.">
					comment = <"Om möjligt, koda systemet eller strukturen med hjälp av ett terminologisystem.">
				>
				["at0003"] = <
					text = <"Klinisk beskrivning">
					description = <"En övergripande beskrivning av fynden från den fysiska undersökningen. ">
				>
				["at0004"] = <
					text = <"Fynd vid undersökning">
					description = <"Strukturerade detaljer om fynd vid den fysiska undersökningen.">
				>
				["at0005"] = <
					text = <"Multimedia-representation">
					description = <"Digital bild, video eller diagram som återger fynd från undersökningen.">
				>
				["at0006"] = <
					text = <"Klinisk tolkning">
					description = <"Ord, fras eller kort beskrivning av fyndens kliniska betydelse.">
					comment = <"*For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. (en)">
				>
				["at0007"] = <
					text = <"Kommentar">
					description = <"Kommentarer avseende undersökningsfynd som inte beskrivs i övriga fält.">
				>
				["at0008"] = <
					text = <"Undersökning ej genomförd">
					description = <"Detaljerad beskrivning om att undersökningen inte genomfördes.">
				>
				["at0011"] = <
					text = <"Strukturerad anatomisk plats">
					description = <"Strukturerad beskrivning av den anatomiska platsen som undersökts.">
					comment = <"Om den anatomiska platsen kan identifieras helt via dataelementet \"System eller struktur som undersökts\" så blir denna del redundant.">
				>
				["at0012"] = <
					text = <"Anatomisk plats">
					description = <"Identifiering av den anatomiska plats som undersökts.
">
					comment = <"Om den anatomiska platsen har identifierats fullt ut i \"System eller struktur som undersökts\" så blir detta element redundant.

">
				>
			>
		>
	>
	term_bindings = <
		["SNOMED-CT"] = <
			items = <
				["at0.1"] = <[SNOMED-CT::362907004]>
				["at0.2"] = <[SNOMED-CT::362908009]>
				["at0000"] = <[SNOMED-CT::5880005]>
			>
		>
	>