Archetype : openEHR-EHR-CLUSTER.breathing_evaluation_reset

OpenEHR Apperta Mirror

Name

Breathing palpation RESET

Description

unknown

Purpose

For recording palpation, percussion and auscultation findings as part of a breathing evaluation in an unscheduled clinical assessment in emergency care.

Use

Use for recording of breathing-related palpation, percussion and auscultation findings specific to an emergency care breathing evaluation.

Misuse

Not to be used for detailed breathing-related palpation, percussion and auscultation findings in contexts other than in emergency care.

Archetype Id

openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0

Licencing

This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.

Original Author

Hildegard Franke
freshEHR Clinical Informatics Ltd.

Date Originally Authored

2016-03-29

Name	Card	Type	Description
Right side palpation finding	0..*	DV_CODED_TEXT	Description of abnormal right side palpation finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Trachea deviated [Palpation indicates that trachea is deviated.] Chest wall tenderness [Palpation indicates that there is chest wall tenderness.] Surgical emphysema [Palpation indicates that there is surgical emphysema.]
Left side palpation finding	0..1	DV_CODED_TEXT	Description of abnormal left side palpation finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Trachea deviated [Palpation indicates that trachea is deviated.] Chest wall tenderness [Palpation indicates that there is chest wall tenderness.] Surgical emphysema [Palpation indicates that there is surgical emphysema.]
Right side percussion finding	0..1	DV_CODED_TEXT	Description of right side percussion finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Normal [Percussion examination indicates normal resonance.] Hyper resonant [Percussion examination indicates hyper-resonance.] Dull [Percussion examination indicates dull resonance.]
Left side percussion finding	0..1	DV_CODED_TEXT	Description of left side percussion finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Normal [Percussion examination indicates normal resonance.] Hyper resonant [Percussion examination indicates hyper-resonance.] Dull [Percussion examination indicates dull resonance.]
Right side auscultation air entry finding	0..1	DV_CODED_TEXT	Description of right side auscultation airway entry finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Good [Auscultation indicates that airway entry is good.] Reduced + [Auscultation indicates that airway entry is slightly reduced.] Reduced ++ [Auscultation indicates that airway entry is very reduced.] Absent [Auscultation indicates that airway entry is absent.]
Right side ausculation added sounds finding	0..1	DV_CODED_TEXT	Description of right side auscultation added sounds finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Wheeze [Auscultation indicates wheeze.] Creps [Auscultation indicates creps.] None [Auscultation indicates no added sounds.]
Left side auscultation air entry finding	0..1	DV_CODED_TEXT	Description of left side auscultation airway entry finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Good [Auscultation indicates that airway entry is good.] Reduced + [Auscultation indicates that airway entry is slightly reduced.] Reduced ++ [Auscultation indicates that airway entry is very reduced.] Absent [Auscultation indicates that airway entry is absent.]
Left side auscultaiton added sounds finding	0..1	DV_CODED_TEXT	Description of left side auscultation airway entry finding as part of breathing evaluation. Constraint for DV_CODED_TEXT Wheeze [Auscultation indicates wheeze.] Creps [Auscultation indicates creps.] None [Auscultation indicates no added sounds.]

archetype (adl_version=1.4; uid=c34dc110-2533-4d16-8661-09d47f984c2e)
	openEHR-EHR-CLUSTER.breathing_evaluation_reset.v0

concept
	[at0000]	-- Breathing palpation RESET
language
	original_language = <[ISO_639-1::en]>
description
	original_author = <
		["name"] = <"Hildegard Franke">
		["organisation"] = <"freshEHR Clinical Informatics Ltd.">
		["email"] = <"hildi@freshehr.com">
		["date"] = <"2016-03-29">
	>
	details = <
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"For recording palpation, percussion and auscultation findings as part of a breathing evaluation in an unscheduled clinical assessment in emergency care.">
			use = <"Use for recording of breathing-related palpation, percussion and auscultation findings specific to an emergency care breathing evaluation.">
			misuse = <"Not to be used for detailed breathing-related palpation, percussion and auscultation findings in contexts other than in emergency care.">
			copyright = <"© Clinical Models UK">
		>
	>
	lifecycle_state = <"in_development">
	other_contributors = <>
	other_details = <
		["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/.">
		["custodian_organisation"] = <"UK Clinical Models">
		["current_contact"] = <"Hildegard Franke, freshEHR Clinical Informatics Ltd.<hildi@freshehr.com>">
		["original_namespace"] = <"uk.org.clinicalmodels">
		["original_publisher"] = <"UK Clinical Models">
		["custodian_namespace"] = <"uk.org.clinicalmodels">
		["MD5-CAM-1.0.1"] = <"F06A8BAF88BB3725130682997860749D">
		["build_uid"] = <"efd412ff-1fad-4666-a89b-1c186fb00687">
		["revision"] = <"0.0.1-alpha">
	>

definition
	CLUSTER[at0000] matches {	-- Breathing palpation RESET
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0002] occurrences matches {0..*} matches {	-- Right side palpation finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0003, 	-- Trachea deviated
							at0004, 	-- Chest wall tenderness
							at0005]	-- Surgical emphysema
						}
					}
				}
			}
			ELEMENT[at0007] occurrences matches {0..1} matches {	-- Left side palpation finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0003, 	-- Trachea deviated
							at0004, 	-- Chest wall tenderness
							at0005]	-- Surgical emphysema
						}
					}
				}
			}
			ELEMENT[at0008] occurrences matches {0..1} matches {	-- Right side percussion finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0014, 	-- Normal
							at0015, 	-- Hyper resonant
							at0016]	-- Dull
						}
					}
				}
			}
			ELEMENT[at0009] occurrences matches {0..1} matches {	-- Left side percussion finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0014, 	-- Normal
							at0015, 	-- Hyper resonant
							at0016]	-- Dull
						}
					}
				}
			}
			ELEMENT[at0010] occurrences matches {0..1} matches {	-- Right side auscultation air entry finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0017, 	-- Good
							at0018, 	-- Reduced +
							at0019, 	-- Reduced ++
							at0020]	-- Absent
						}
					}
				}
			}
			ELEMENT[at0012] occurrences matches {0..1} matches {	-- Right side ausculation added sounds finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0021, 	-- Wheeze
							at0022, 	-- Creps
							at0023]	-- None
						}
					}
				}
			}
			ELEMENT[at0011] occurrences matches {0..1} matches {	-- Left side auscultation air entry finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0017, 	-- Good
							at0018, 	-- Reduced +
							at0019, 	-- Reduced ++
							at0020]	-- Absent
						}
					}
				}
			}
			ELEMENT[at0013] occurrences matches {0..1} matches {	-- Left side auscultaiton added sounds finding
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0021, 	-- Wheeze
							at0022, 	-- Creps
							at0023]	-- None
						}
					}
				}
			}
		}
	}


ontology
	term_definitions = <
		["en"] = <
			items = <
				["at0000"] = <
					text = <"Breathing palpation RESET">
					description = <"unknown">
				>
				["at0002"] = <
					text = <"Right side palpation finding">
					description = <"Description of abnormal right side palpation finding as part of breathing evaluation.">
				>
				["at0003"] = <
					text = <"Trachea deviated">
					description = <"Palpation indicates that trachea is deviated.">
				>
				["at0004"] = <
					text = <"Chest wall tenderness">
					description = <"Palpation indicates that there is chest wall tenderness.">
				>
				["at0005"] = <
					text = <"Surgical emphysema">
					description = <"Palpation indicates that there is surgical emphysema.">
				>
				["at0007"] = <
					text = <"Left side palpation finding">
					description = <"Description of abnormal left side palpation finding as part of breathing evaluation.">
				>
				["at0008"] = <
					text = <"Right side percussion finding">
					description = <"Description of right side percussion finding as part of breathing evaluation.">
				>
				["at0009"] = <
					text = <"Left side percussion finding">
					description = <"Description of left side percussion finding as part of breathing evaluation.">
				>
				["at0010"] = <
					text = <"Right side auscultation air entry finding">
					description = <"Description of right side auscultation airway entry finding as part of breathing evaluation.">
				>
				["at0011"] = <
					text = <"Left side auscultation air entry finding">
					description = <"Description of left side auscultation airway entry finding as part of breathing evaluation.">
				>
				["at0012"] = <
					text = <"Right side ausculation added sounds finding">
					description = <"Description of right side auscultation added sounds finding as part of breathing evaluation.">
				>
				["at0013"] = <
					text = <"Left side auscultaiton added sounds finding">
					description = <"Description of left side auscultation airway entry finding as part of breathing evaluation.">
				>
				["at0014"] = <
					text = <"Normal">
					description = <"Percussion examination indicates normal resonance.">
				>
				["at0015"] = <
					text = <"Hyper resonant">
					description = <"Percussion examination indicates hyper-resonance.">
				>
				["at0016"] = <
					text = <"Dull">
					description = <"Percussion examination indicates dull resonance.">
				>
				["at0017"] = <
					text = <"Good">
					description = <"Auscultation indicates that airway entry is good.">
				>
				["at0018"] = <
					text = <"Reduced +">
					description = <"Auscultation indicates that airway entry is slightly reduced.">
				>
				["at0019"] = <
					text = <"Reduced ++">
					description = <"Auscultation indicates that airway entry is very reduced.">
				>
				["at0020"] = <
					text = <"Absent">
					description = <"Auscultation indicates that airway entry is absent.">
				>
				["at0021"] = <
					text = <"Wheeze">
					description = <"Auscultation indicates wheeze.">
				>
				["at0022"] = <
					text = <"Creps">
					description = <"Auscultation indicates creps.">
				>
				["at0023"] = <
					text = <"None">
					description = <"Auscultation indicates no added sounds.">
				>
			>
		>
	>