OpenEHR Master CKM Mirror
Name
Examination findings of a muscle group
Description
Findings observed during the physical examination of a single muscle or a muscle group.
Purpose
To record the findings observed during the physical examination of a single muscle or a muscle group.
Use
Use to record the observed findings during the physical examination of a single muscle or a muscle group.
This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetypes, or the CLUSTER.exam-joint family of archetypes.It can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Further specialisations of this archetype can be used to record examination findings for identified muscles or muscle groups.
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.
This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetypes, or the CLUSTER.exam-joint family of archetypes.It can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Further specialisations of this archetype can be used to record examination findings for identified muscles or muscle groups.
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.
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.
Not to be used for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose.
Archetype Id
openEHR-EHR-CLUSTER.exam-muscle_group.v0
Copyright
© 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
Heather Leslie
Atomica Informatics
Atomica Informatics
Date Originally Authored
2015-06-23
| Language | Details |
|---|---|
| German |
Nina Schewe, Martin Koch
Medizinische Hochschule Hannover, Servei Català de la Salut
|
| Swedish |
Erik Sundvall
Region Östergötland + Linköping University
|
| Norwegian Bokmal |
Silje Ljosland Bakke, Vebjørn Arntzen
Nasjonal IKT HF, Oslo University Hospital
|
| Portuguese (Brazil) |
Adriana Kitajima
Hospital Alemão Oswaldo Cruz - HAOC
|
| Name | Card | Type | Description |
|---|---|---|---|
|
Muscle group
|
1..1 | DV_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.
|
|
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
|
|
Fasciculation
|
0..1 | DV_CODED_TEXT |
Constraint for DV_CODED_TEXT
|
|
Atrophy
|
0..1 | DV_CODED_TEXT |
Constraint for DV_CODED_TEXT
|
|
Hypertrophy
|
0..1 | DV_CODED_TEXT |
Constraint for DV_CODED_TEXT
|
|
Tenderness
|
0..1 | DV_CODED_TEXT |
Constraint for DV_CODED_TEXT
|
|
Strength
|
0..1 | DV_ORDINAL |
Constraint for DV_ORDINAL
|
archetype (adl_version=1.4; uid=5abeacd7-0a9e-4608-b28c-0607fc65477b) openEHR-EHR-CLUSTER.exam-muscle_group.v0 specialise openEHR-EHR-CLUSTER.exam.v2 concept [at0000.1] -- Examination findings of a muscle group language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Nina Schewe, Martin Koch"> ["organisation"] = <"Medizinische Hochschule Hannover, Servei Català de la Salut"> ["email"] = <"schewe.nina@mh-hannover.de, martinandreaskoch@catsalut.cat"> > > ["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"] = <"Silje Ljosland Bakke, Vebjørn Arntzen"> ["organisation"] = <"Nasjonal IKT HF, Oslo University Hospital"> ["email"] = <"varntzen@ous-hf.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"] = <"Heather Leslie"> ["organisation"] = <"Atomica Informatics"> ["email"] = <"heather.leslie@atomicainformatics.com"> ["date"] = <"2015-06-23"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"Zur Aufzeichnung der bei der körperlichen Untersuchung eines einzelnen Muskels oder einer Muskelgruppe beobachteten Befunde."> use = <"Zur Erfassung der beobachteten Befunde bei der körperlichen Untersuchung eines einzelnen Muskels oder einer Muskelgruppe. Dieser Archetyp wurde speziell für den SLOT „Untersuchungsdetails“ innerhalb der Archetypen OBSERVATION.exam, CLUSTER.exam-nervous_system oder der Archetypenfamilie CLUSTER.exam-joint entwickelt. Er kann, sofern klinisch sinnvoll, auch innerhalb anderer ENTRY- oder CLUSTER-Archetypen verwendet werden. Weitere Spezialisierungen dieses Archetyps ermöglichen die Erfassung von Untersuchungsbefunden für identifizierte Muskeln oder Muskelgruppen. Die Interpretation der Befunde, z. B. „Keine Auffälligkeit festgestellt“ oder „Mäßige Entzündung vorhanden“, kann mit dem Datenelement „Klinische Interpretation“ erfasst werden. Dient als Rahmen, in dem CLUSTER-Archetypen in den SLOT „Untersuchungsbefunde“ eingebettet werden können, um zusätzliche strukturierte Befunde aus körperlichen Untersuchungen zu erfassen. Der Archetyp CLUSTER.exclusion_exam kann im SLOT „Untersuchung nicht durchgeführt“ verschachtelt werden, um optional explizite Details zur nicht durchgeführten Untersuchung aufzuzeichnen. Verwenden Sie ihn, um die narrativen Beschreibungen klinischer Befunde in bestehenden oder älteren klinischen Systemen mithilfe des Datenelements „Klinische Beschreibung“ in ein archetypisiertes Format zu integrieren."> misuse = <"Nicht zur Aufzeichnung der Krankengeschichte verwenden. Verwenden Sie hierfür die spezifischen Archetypen „OBSERVATION“ und „CLUSTER“. Zum Beispiel „OBSERVATION.story“ und „CLUSTER.symptom_sign“. Nicht zur Aufzeichnung der Ergebnisse einer bildgebenden Untersuchung verwenden. Verwenden Sie hierfür die Archetypenfamilie „CLUSTER.imaging_exam“."> > ["sv"] = < language = <[ISO_639-1::sv]> purpose = <"*To record the findings observed during the physical examination of a single muscle or a muscle group. (en)"> use = <"*Use to record the observed findings during the physical examination of a single muscle or a muscle group. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetypes, or the CLUSTER.exam-joint family of archetypes.It can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Further specialisations of this archetype can be used to record examination findings for identified muscles or muscle groups. 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 = <"fynd, undersökningsfynd, fysisk undersökning, u.a., utan anmärkning", ...> 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)"> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"*To record the findings observed during the physical examination of a single muscle or a muscle group. (en)"> use = <"*Use to record the observed findings during the physical examination of a single muscle or a muscle group. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetypes, or the CLUSTER.exam-joint family of archetypes.It can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Further specialisations of this archetype can be used to record examination findings for identified muscles or muscle groups. 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)"> 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 arketype innen gruppen av CLUSTER.imaging_exam (Bildeundersøkelse) for dette."> > ["pt-br"] = < language = <[ISO_639-1::pt-br]> purpose = <"*To record the findings observed during the physical examination of a single muscle or a muscle group. (en)"> use = <"*Use to record the observed findings during the physical examination of a single muscle or a muscle group. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetypes, or the CLUSTER.exam-joint family of archetypes.It can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Further specialisations of this archetype can be used to record examination findings for identified muscles or muscle groups. 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)"> 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)"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record the findings observed during the physical examination of a single muscle or a muscle group."> use = <"Use to record the observed findings during the physical examination of a single muscle or a muscle group. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the CLUSTER.exam-nervous_system archetypes, or the CLUSTER.exam-joint family of archetypes.It can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Further specialisations of this archetype can be used to record examination findings for identified muscles or muscle groups. 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."> 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 = <"© openEHR Foundation"> > > lifecycle_state = <"in_development"> other_contributors = <"Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)", "Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)", "SB Bhattacharyya, Sudisa Consultancy Services, India", "Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway", "Shahla Foozonkhah, Iran ministry of health and education, Iran", "Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)", "Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)", "Ingrid Heitmann, Oslo universitetssykehus HF, Norway", "Hilde Hollås, DIPS ASA, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Lars Ivar Mehlum, Helse Bergen HF, Norway", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom", "Lars Morgan Karlsen, DIPS ASA, Norway", "Bjørn Næss, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Vladimir Pizzo, Hospital Sírio Libanês, Brazil", "Jussara Rotzsch, UNB, Brazil", "Anoop Shah, University College London, United Kingdom", "Line Silsand, Universitetssykehuset i Nord-Norge, Norway", "Norwegian Review Summary, Nasjonal IKT HF, Norway", "Nyree Taylor, Ocean Informatics, Australia (openEHR Editor)", "Rowan Thomas, St. Vincent's Hospital Melbourne, Australia", "Jon Tysdahl, Furst medlab AS, Norway", "John Tore Valand, Helse Bergen, Norway (openEHR Editor)"> 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"> ["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"] = <"A62633B63060E958A076957F20C9DC0A"> ["build_uid"] = <"d817fb15-3a05-4e5a-b480-e238b672a399"> ["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 http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org."> ["revision"] = <"0.0.1-alpha"> > definition CLUSTER[at0000.1] matches { -- Examination findings of a muscle group items cardinality matches {1..*; unordered} matches { ELEMENT[at0001.1] matches { -- Muscle group value matches { DV_TEXT matches {*} } } 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/} } ELEMENT[at0.1] occurrences matches {0..1} matches { -- Fasciculation value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.2, -- Present at0.3, -- Indeterminate at0.4] -- Absent } } } } ELEMENT[at0.5] occurrences matches {0..1} matches { -- Atrophy value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.6, -- Present at0.7, -- Indeterminate at0.8] -- Absent } } } } ELEMENT[at0.9] occurrences matches {0..1} matches { -- Hypertrophy value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.10, -- Present at0.11, -- Indeterminate at0.12] -- Absent } } } } ELEMENT[at0.13] occurrences matches {0..1} matches { -- Tenderness value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.14, -- Present at0.15, -- Indeterminate at0.16] -- Absent } } } } ELEMENT[at0.17] occurrences matches {0..1} matches { -- Strength value matches { 0|[local::at0.18], 1|[local::at0.19], 2|[local::at0.20], 3|[local::at0.21], 4|[local::at0.22], 5|[local::at0.23] } } } } ontology term_definitions = < ["en"] = < items = < ["at0000.1"] = < text = <"Examination findings of a muscle group"> description = <"Findings observed during the physical examination of a single muscle or a muscle group."> > ["at0001.1"] = < text = <"Muscle group"> 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."> > ["at0.1"] = < text = <"Fasciculation"> description = <""> > ["at0.2"] = < text = <"Present"> description = <""> > ["at0.3"] = < text = <"Indeterminate"> description = <""> > ["at0.4"] = < text = <"Absent"> description = <""> > ["at0.5"] = < text = <"Atrophy"> description = <""> > ["at0.6"] = < text = <"Present"> description = <""> > ["at0.7"] = < text = <"Indeterminate"> description = <""> > ["at0.8"] = < text = <"Absent"> description = <""> > ["at0.9"] = < text = <"Hypertrophy"> description = <""> > ["at0.10"] = < text = <"Present"> description = <""> > ["at0.11"] = < text = <"Indeterminate"> description = <""> > ["at0.12"] = < text = <"Absent"> description = <""> > ["at0.13"] = < text = <"Tenderness"> description = <""> > ["at0.14"] = < text = <"Present"> description = <""> > ["at0.15"] = < text = <"Indeterminate"> description = <""> > ["at0.16"] = < text = <"Absent"> description = <""> > ["at0.17"] = < text = <"Strength"> description = <""> > ["at0.18"] = < text = <"No visible muscle contraction"> description = <""> > ["at0.19"] = < text = <"Visible muscle contraction with no or trace movement"> description = <""> > ["at0.20"] = < text = <"Limb movement, but not against gravity"> description = <""> > ["at0.21"] = < text = <"Movement against gravity but not resistance"> description = <""> > ["at0.22"] = < text = <"Movement against at least some resistance supplied by the examiner"> description = <""> > ["at0.23"] = < text = <"Full strength"> description = <""> > ["at0000"] = < text = <"Examination findings"> description = <"Findings observed during the physical examination of a body system or anatomical structure."> > ["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."> > ["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 = < ["at0000.1"] = < text = <"*Examination findings of a muscle group (en)"> description = <"*Findings observed during the physical examination of a single muscle or a muscle group. (en)"> > ["at0001.1"] = < text = <"*Muscle group (en)"> 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."> > ["at0.1"] = < text = <"*Fasciculation (en)"> description = <""> > ["at0.2"] = < text = <"*Present (en)"> description = <""> > ["at0.3"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.4"] = < text = <"*Absent (en)"> description = <""> > ["at0.5"] = < text = <"*Atrophy (en)"> description = <""> > ["at0.6"] = < text = <"*Present (en)"> description = <""> > ["at0.7"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.8"] = < text = <"*Absent (en)"> description = <""> > ["at0.9"] = < text = <"*Hypertrophy (en)"> description = <""> > ["at0.10"] = < text = <"*Present (en)"> description = <""> > ["at0.11"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.12"] = < text = <"*Absent (en)"> description = <""> > ["at0.13"] = < text = <"*Tenderness (en)"> description = <""> > ["at0.14"] = < text = <"*Present (en)"> description = <""> > ["at0.15"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.16"] = < text = <"*Absent (en)"> description = <""> > ["at0.17"] = < text = <"*Strength (en)"> description = <""> > ["at0.18"] = < text = <"*No visible muscle contraction (en)"> description = <""> > ["at0.19"] = < text = <"*Visible muscle contraction with no or trace movement (en)"> description = <""> > ["at0.20"] = < text = <"*Limb movement, but not against gravity (en)"> description = <""> > ["at0.21"] = < text = <"*Movement against gravity but not resistance (en)"> description = <""> > ["at0.22"] = < text = <"*Movement against at least some resistance supplied by the examiner (en)"> description = <""> > ["at0.23"] = < text = <"*Full strength (en)"> description = <""> > ["at0000"] = < text = <"Undersøkelsesfunn"> description = <"Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur."> > ["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."> > ["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 = < ["at0000.1"] = < text = <"*Examination findings of a muscle group (en)"> description = <"*Findings observed during the physical examination of a single muscle or a muscle group. (en)"> > ["at0001.1"] = < text = <"*Muscle group (en)"> 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."> > ["at0.1"] = < text = <"*Fasciculation (en)"> description = <""> > ["at0.2"] = < text = <"*Present (en)"> description = <""> > ["at0.3"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.4"] = < text = <"*Absent (en)"> description = <""> > ["at0.5"] = < text = <"*Atrophy (en)"> description = <""> > ["at0.6"] = < text = <"*Present (en)"> description = <""> > ["at0.7"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.8"] = < text = <"*Absent (en)"> description = <""> > ["at0.9"] = < text = <"*Hypertrophy (en)"> description = <""> > ["at0.10"] = < text = <"*Present (en)"> description = <""> > ["at0.11"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.12"] = < text = <"*Absent (en)"> description = <""> > ["at0.13"] = < text = <"*Tenderness (en)"> description = <""> > ["at0.14"] = < text = <"*Present (en)"> description = <""> > ["at0.15"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.16"] = < text = <"*Absent (en)"> description = <""> > ["at0.17"] = < text = <"*Strength (en)"> description = <""> > ["at0.18"] = < text = <"*No visible muscle contraction (en)"> description = <""> > ["at0.19"] = < text = <"*Visible muscle contraction with no or trace movement (en)"> description = <""> > ["at0.20"] = < text = <"*Limb movement, but not against gravity (en)"> description = <""> > ["at0.21"] = < text = <"*Movement against gravity but not resistance (en)"> description = <""> > ["at0.22"] = < text = <"*Movement against at least some resistance supplied by the examiner (en)"> description = <""> > ["at0.23"] = < text = <"*Full strength (en)"> description = <""> > ["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 = <"Faszikulation"> description = <""> > ["at0.10"] = < text = <"Vorhanden"> description = <""> > ["at0.11"] = < text = <"Unbestimmt"> description = <""> > ["at0.12"] = < text = <"Abwesend"> description = <""> > ["at0.13"] = < text = <"Empfindlichkeit"> description = <""> > ["at0.14"] = < text = <"Vorhanden"> description = <""> > ["at0.15"] = < text = <"Unbestimmt"> description = <""> > ["at0.16"] = < text = <"Abwesend"> description = <""> > ["at0.17"] = < text = <"Stärke"> description = <""> > ["at0.18"] = < text = <"Keine sichtbare Muskelkontraktion"> description = <""> > ["at0.19"] = < text = <"Sichtbare Muskelkontraktion ohne oder mit nur geringen Bewegungen"> description = <""> > ["at0.2"] = < text = <"Vorhanden"> description = <""> > ["at0.20"] = < text = <"Bewegung der Gliedmaßen, aber nicht gegen die Schwerkraft"> description = <""> > ["at0.21"] = < text = <"Bewegung gegen die Schwerkraft, aber ohne Widerstand"> description = <""> > ["at0.22"] = < text = <"Bewegung gegen zumindest einen gewissen Widerstand des Prüfers"> description = <""> > ["at0.23"] = < text = <"Volle Stärke"> description = <""> > ["at0.3"] = < text = <"Unbestimmt"> description = <""> > ["at0.4"] = < text = <"Abwesend"> description = <""> > ["at0.5"] = < text = <"Atrophie"> description = <""> > ["at0.6"] = < text = <"Vorhanden"> description = <""> > ["at0.7"] = < text = <"Unbestimmt"> description = <""> > ["at0.8"] = < text = <"Abwesend"> description = <""> > ["at0.9"] = < text = <"Hypertrophie"> description = <""> > ["at0000"] = < text = <"Untersuchungsergebnisse"> description = <"Während der körperlichen Untersuchung eines Körpersystems oder einer anatomischen Struktur beobachtete Befunde."> > ["at0000.1"] = < text = <"Untersuchungsbefund einer Muskelgruppe"> description = <"Befunde, die bei der körperlichen Untersuchung eines einzelnen Muskels oder einer Muskelgruppe beobachtet werden."> > ["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."> > ["at0001.1"] = < text = <"Muskelgruppe"> 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 = <"Zum Beispiel: „Keine Anomalie festgestellt“ oder „Mäßige Entzündung vorhanden“. Die Kodierung der „Klinischen Interpretation“ mit einer Terminologie wird nach Möglichkeit bevorzugt."> > ["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 = < ["at0000.1"] = < text = <"*Examination findings of a muscle group (en)"> description = <"*Findings observed during the physical examination of a single muscle or a muscle group. (en)"> > ["at0001.1"] = < text = <"*Muscle group (en)"> description = <"Identifiering av systemet eller strukturen som undersökts."> comment = <"Om möjligt, koda systemet eller strukturen med hjälp av ett terminologisystem."> > ["at0.1"] = < text = <"*Fasciculation (en)"> description = <""> > ["at0.2"] = < text = <"*Present (en)"> description = <""> > ["at0.3"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.4"] = < text = <"*Absent (en)"> description = <""> > ["at0.5"] = < text = <"*Atrophy (en)"> description = <""> > ["at0.6"] = < text = <"*Present (en)"> description = <""> > ["at0.7"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.8"] = < text = <"*Absent (en)"> description = <""> > ["at0.9"] = < text = <"*Hypertrophy (en)"> description = <""> > ["at0.10"] = < text = <"*Present (en)"> description = <""> > ["at0.11"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.12"] = < text = <"*Absent (en)"> description = <""> > ["at0.13"] = < text = <"*Tenderness (en)"> description = <""> > ["at0.14"] = < text = <"*Present (en)"> description = <""> > ["at0.15"] = < text = <"*Indeterminate (en)"> description = <""> > ["at0.16"] = < text = <"*Absent (en)"> description = <""> > ["at0.17"] = < text = <"*Strength (en)"> description = <""> > ["at0.18"] = < text = <"*No visible muscle contraction (en)"> description = <""> > ["at0.19"] = < text = <"*Visible muscle contraction with no or trace movement (en)"> description = <""> > ["at0.20"] = < text = <"*Limb movement, but not against gravity (en)"> description = <""> > ["at0.21"] = < text = <"*Movement against gravity but not resistance (en)"> description = <""> > ["at0.22"] = < text = <"*Movement against at least some resistance supplied by the examiner (en)"> description = <""> > ["at0.23"] = < text = <"*Full strength (en)"> description = <""> > ["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. "> > > > >