Modellbiblioteket openEHR Fork
Name
Examination of cranial nerves
Description
Findings observed during the physical examination of the cranial nerves.
Purpose
To record a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves.
Use
Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or CLUSTER.exam-nervous_system archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate.

Use to provide a framework in which CLUSTER archetypes for each cranial nerve can be nested in the appropriate SLOTs and other 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 to record the results of visual field testing - use OBSERVATION.visual_field_measurement for this purpose.

Not to be used to record the results of visual acuity testing - use OBSERVATION.visual_acuity for this purpose.
Archetype Id
openEHR-EHR-CLUSTER.exam-cranial_nerves.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
Date Originally Authored
To record a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves.
Language Details
German
Nina Schewe, Natalia Strauch, Darin Leonhardt
Medizinische Hochschule Hannover, PLRI für medizinische Informatik/ Medizinische Hochschule
Swedish
Erik Sundvall
Region Östergötland + Linköping University
Norwegian Bokmal
Silje Ljosland Bakke
Nasjonal IKT HF
Portuguese (Brazil)
Adriana Kitajima
Hospital Alemão Oswaldo Cruz - HAOC
Greek
Erasmia Partafylla
Sigmasoft
Spanish, Castilian
Julio de Sosa
Servei Català de la Salut
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
  • Cranial nerve
    [One of each of twelve pairs of nerves which arise directly from the brain.]
Body site
0..1 DV_TEXT Identification of the area of the body under examination.
Comment
For example examination of a specific area of skin. 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
I description
0..1 DV_TEXT Narrative description about findings on examination of the olfactory nerve.
Comment
For example: summary about smell testing.
I details
0..* Slot (Cluster) Details about function of the olfactory nerve.
Slot
Slot
II description
0..1 DV_TEXT Narrative description about findings on examination of the optic nerve.
II details
0..* Slot (Cluster) Details about the function of the optic nerve.
Slot
Slot
III, IV & VI description
0..1 DV_TEXT Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves.
III, IV & VI details
0..* Slot (Cluster) Details about the function of the oculomotor, trochlear and abducens nerves.
Slot
Slot
V description
0..1 DV_TEXT Narrative description about findings on examination of the trigeminal nerve.
Corneal reflex
0..1 DV_CODED_TEXT The presence of the corneal reflex.
Comment
Also known as the 'blink reflex'.
Constraint for DV_CODED_TEXT
  • Present
    [The reflex is observed.]
  • Absent
    [The reflex is not observed.]
  • Reduced
    [The reflex is observed, but diminished compared to normal.]
Jaw jerk
0..1 DV_CODED_TEXT The presence of the jaw jerk.
Constraint for DV_CODED_TEXT
  • Present
    [The jaw jerk is present.]
  • Absent
    [The jaw jerk is absent.]
V details
0..* Slot (Cluster) Details about the function of the trigeminal nerve.
Slot
Slot
VII description
0..1 DV_TEXT Narrative description about findings on examination of the facial nerve.
VII details
0..* Slot (Cluster) Details about the function of the facial nerve.
Slot
Slot
VIII description
0..1 DV_TEXT Narrative description about findings on examination of the vestibulococchlear nerve.
VIII details
0..* Slot (Cluster) Details about the function of the vestibulococchlear nerve.
Slot
Slot
IX & X description
0..1 DV_TEXT Narrative description about findings on examination of the glossopharyngeal and vagus nerves.
Gag reflex
0..1 DV_CODED_TEXT The presence of the pharyngeal, or gag, reflex.
Constraint for DV_CODED_TEXT
  • Present
    [The reflex is observed.]
  • Absent
    [The reflex is not observed.]
  • Reduced
    [The reflex is observed, but diminished compared to normal.]
IX & X details
0..* Slot (Cluster) Details about the function of the glossopharyngeal and vagus nerves.
Slot
Slot
XI description
0..1 DV_TEXT Narrative description about findings on examination of the accessory nerve.
XI details
0..* Slot (Cluster) Details about the function of the accessory nerve.
Slot
Slot
XII description
0..1 DV_TEXT Narrative description about findings on examination of the hypoglossal nerve.
XII details
0..* Slot (Cluster) Details about the function of the hypoglossal nerve.
Slot
Slot
archetype (adl_version=1.4; uid=c189c249-abad-40de-908c-5c3c39308aef)
	openEHR-EHR-CLUSTER.exam-cranial_nerves.v0
specialise
	openEHR-EHR-CLUSTER.exam.v2

concept
	[at0000.1]	-- Examination of cranial nerves
language
	original_language = <[ISO_639-1::en]>
	translations = <
		["de"] = <
			language = <[ISO_639-1::de]>
			author = <
				["name"] = <"Nina Schewe, Natalia Strauch, Darin Leonhardt">
				["organisation"] = <"Medizinische Hochschule Hannover, PLRI für medizinische Informatik/ Medizinische Hochschule">
				["email"] = <"schewe.nina@mh-hannover.de, Strauch.Natalia@mh-hannover.de, leonhardt.darin@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"] = <"Silje Ljosland Bakke">
				["organisation"] = <"Nasjonal IKT HF">
			>
		>
		["pt-br"] = <
			language = <[ISO_639-1::pt-br]>
			author = <
				["name"] = <"Adriana Kitajima">
				["organisation"] = <"Hospital Alemão Oswaldo Cruz - HAOC">
				["email"] = <"adrianakitajima@gmail.com">
			>
		>
		["el"] = <
			language = <[ISO_639-1::el]>
			author = <
				["name"] = <"Erasmia Partafylla">
				["organisation"] = <"Sigmasoft">
				["email"] = <"c.partafylla@sigmasoft.gr">
			>
		>
		["es"] = <
			language = <[ISO_639-1::es]>
			author = <
				["name"] = <"Julio de Sosa">
				["organisation"] = <"Servei Català de la Salut">
				["email"] = <"juliodesosa@catsalut.cat">
			>
		>
	>
description
	original_author = <
		["name"] = <"Heather Leslie">
		["organisation"] = <"Atomica Informatics">
		["email"] = <"heather.leslie@atomicainformatics.com">
		["date"] = <"2015-06-24">
	>
	details = <
		["de"] = <
			language = <[ISO_639-1::de]>
			purpose = <"Aufzeichnung der bei der körperlichen Untersuchung eines Körpersystems oder einer anatomischen Struktur beobachteten Befunde.">
			use = <"Zur Aufzeichnung der beobachteten Befunde während der körperlichen Untersuchung eines Körpersystems oder einer anatomischen Struktur.

Dieser Archetyp wurde speziell für die Verwendung im SLOT „Untersuchungsdetails“ innerhalb des Archetyps OBSERVATION.exam oder im SLOT „Verfahrensdetails“ innerhalb des Archetyps ACTION.procedure entwickelt, kann aber auch innerhalb anderer Archetypen ENTRY oder CLUSTER verwendet werden, sofern dies klinisch sinnvoll ist. Spezialisierungen dieses Archetyps werden verwendet, um Untersuchungsergebnisse für bestimmte Körpersysteme, anatomische Strukturen oder genauere Körperstellen zu erfassen. Jede Spezialisierung behält die Grundstruktur dieses allgemeinen Archetyps als Basis bei und wird durch die Hinzufügung von Elementen erweitert, die für die Körperstelle spezifisch sind. Steht keine geeignete Spezialisierung zur Verfügung, ist dieser Archetyp zu verwenden und das untersuchte System oder die untersuchte Struktur mit dem Datenelement „System oder untersuchte Struktur“ und die Körperstelle mit dem Datenelement „Körperstelle“ oder dem SLOT „Strukturierte Körperstelle“ anzugeben.

Die Interpretation der Befunde, z. B. „Keine Abnormität festgestellt“ oder „Mäßige Entzündung vorhanden“, kann mit dem Datenelement „Klinische Interpretation“ erfasst werden.

Verwendung zur Bereitstellung eines Rahmens, in dem CLUSTER-Archetypen im SLOT „Untersuchungsbefund“ verschachtelt werden können, um zusätzliche strukturierte körperliche Untersuchungsbefunde zu erfassen.

Der Archetyp CLUSTER.exclusion_exam kann in den SLOT „Nicht durchgeführte Untersuchung“ geschachtelt werden, um optional explizite Details über die nicht durchgeführte Untersuchung zu erfassen.

Verwenden Sie das Datenelement „Klinische Beschreibung“, um die narrativen Beschreibungen klinischer Befunde innerhalb bestehender oder vorhandener klinischer Systeme in ein archetypisches Format einzubinden.">
			misuse = <"Nicht zur Darstellung der klinischen Anamnese zu verwenden – verwenden Sie spezifische OBSERVATION- und CLUSTER-Archetypen. Zum Beispiel OBSERVATION.story und CLUSTER.symptom_sign.

Nicht zur Darstellung der Ergebnisse einer bildgebenden Untersuchung verwenden – verwenden Sie für diesen Zweck die Archetypenfamilie CLUSTER.imaging_exam.">
		>
		["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 will be used to record examination findings for identified body systems, anatomical structures or more precise body sites. Each specialisation will preserve the underlying structure of this general archetype as its base and be extended by the addition of elements specific to the body site. 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 = <"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 = <"For å registrere en fritekstbeskrivelse og klinisk tolkning av observerte funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur.">
			use = <"Brukes til å registrere en fritekstbeskrivelse og klinisk tolkning av observerte funn ved fysisk undersøkelse av et spesifisert organsystem eller anatomisk struktur. Denne arketypen består kun av kjerneelementene av mønsteret for undersøkelser, og kan utvides ved hjelp av andre CLUSTER-arketyper eller brukes som grunnlag for undersøkelsesarketyper for spesifikke kroppssystemer eller anatomiske strukturer. 

Eksempler på detaljer som kan beskrives ved hjelp av dette CLUSTER er inspeksjon, palpasjon, auskultasjon, perkusjon og bevegelser i kroppssystemer eller anatomiske strukturer. Undersøkelsen kan støttes av enkle hjelpemidler som stetoskop, otoskop eller reflekshammer. Også funn ved mer avanserte undersøkelser kan registreres her, som ved endoskopi. I de tilfellene vil informasjon om hvilket hjelpemiddel eller utstyr brukt bli registrert i OBSERVATION.exam, elementet \"Detaljer om medisinsk utstyr\", i ACTION.procedure \"Prosedyredetaljer\" eller tilsvarende i egnet ENTRY- eller ACTION-arketype.

Arketypen er laget spesifikt for å brukes i \"Undersøkelsesdetaljer\"-SLOTet i arketypen OBSERVATION.exam, men kan også brukes innen andre ENTRY- og CLUSTER-arketyper der det er klinisk passende.

Denne arketypen kan benyttes for alle typer undersøkelser, alt fra enkle undersøkelser som undersøkelse av et hudområde, inspeksjon av ører og til artroskopi av et kne.

Kan for eksempel nøstes i SLOTet \"Undersøkelsesdetaljer\" i arketypen OBSERVATION.exam (Norsk Funn ved fysisk undersøkelse) for å registrere ytterligere strukturerte funn ved fysiske undersøkelser.

Arketypen CLUSTER.exclusion_exam kan nøstes i SLOTet \"Undersøkelse ikke utført\" der en har behov for å registrere informasjon om at en undersøkelse ikke ble utført.

Brukes for å videreføre fritekstbeskrivelser av kliniske funn fra tidligere systemer inn i et arketypeformat, ved å bruke elementet \"Klinisk beskrivelse\".">
			misuse = <"Skal ikke brukes til å ta opp frittstående klinisk observasjoner eller testresultater - bruk spesifikke OBSERVATION arketyper, for eksempel OBSERVATION.head_circumference eller OBSERVATION.glasgow_coma_scale.

Skal ikke brukes til å ta opp anamnese - bruk da spesifikke OBSERVATION og CLUSTER arketyper. For eksempel OBSERVATION.story og CLUSTER.symptom_sign.">
			copyright = <"© 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 will be used to record examination findings for identified body systems, anatomical structures or more precise body sites. Each specialisation will preserve the underlying structure of this general archetype as its base and be extended by the addition of elements specific to the body site. 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)">
			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)">
		>
		["el"] = <
			language = <[ISO_639-1::el]>
			purpose = <"Για την καταγραφή των ευρημάτων που παρατηρούνται κατά τη φυσική εξέταση ενός συστήματος σώματος ή ανατομικής δομής.">
			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 will be used to record examination findings for identified body systems, anatomical structures or more precise body sites. Each specialisation will preserve the underlying structure of this general archetype as its base and be extended by the addition of elements specific to the body site. 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)">
			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 a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves.">
			use = <"Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of the cranial nerves.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or CLUSTER.exam-nervous_system archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate.

Use to provide a framework in which CLUSTER archetypes for each cranial nerve can be nested in the appropriate SLOTs and other 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 to record the results of visual field testing  - use OBSERVATION.visual_field_measurement for this purpose.

Not to be used to record the results of visual acuity testing - use OBSERVATION.visual_acuity for this purpose.">
			copyright = <"© openEHR Foundation">
		>
		["es"] = <
			language = <[ISO_639-1::es]>
			purpose = <"Registrar los hallazgos observados durante la exploración física de un sistema corporal o una estructura anatómica.">
			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 will be used to record examination findings for identified body systems, anatomical structures or more precise body sites. Each specialisation will preserve the underlying structure of this general archetype as its base and be extended by the addition of elements specific to the body site. 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)">
			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)">
		>
	>
	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"] = <"AF092540F908C5382D342E3C1F579AF1">
		["build_uid"] = <"43f93f81-11e9-4b64-889d-b37f994c061d">
		["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 of cranial nerves
		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]    -- Cranial nerve
						}
					}
				}
			}
			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[at0.11] occurrences matches {0..1} matches {    -- I description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0.2] occurrences matches {0..*} matches {    -- I details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1/}
			}
			ELEMENT[at0.12] occurrences matches {0..1} matches {    -- II description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0.3] occurrences matches {0..*} matches {    -- II details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1/}
			}
			ELEMENT[at0.13] occurrences matches {0..1} matches {    -- III, IV & VI description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0.4] occurrences matches {0..*} matches {    -- III, IV & VI details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1|openEHR-EHR-CLUSTER\.exam-pupil\.v0/}
			}
			ELEMENT[at0.14] occurrences matches {0..1} matches {    -- V description
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.20] occurrences matches {0..1} matches {    -- Corneal reflex
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.21,    -- Present
							at0.22,    -- Absent
							at0.23]    -- Reduced
						}
					}
				}
			}
			ELEMENT[at0.24] occurrences matches {0..1} matches {    -- Jaw jerk
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.25,    -- Present
							at0.26]    -- Absent
						}
					}
				}
			}
			allow_archetype CLUSTER[at0.5] occurrences matches {0..*} matches {    -- V details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1/}
			}
			ELEMENT[at0.15] occurrences matches {0..1} matches {    -- VII description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0.6] occurrences matches {0..*} matches {    -- VII details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1|openEHR-EHR-CLUSTER\.exam-face\.v0/}
			}
			ELEMENT[at0.16] occurrences matches {0..1} matches {    -- VIII description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0.7] occurrences matches {0..*} matches {    -- VIII details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1/}
			}
			ELEMENT[at0.17] occurrences matches {0..1} matches {    -- IX & X description
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.27] occurrences matches {0..1} matches {    -- Gag reflex
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.21,    -- Present
							at0.22,    -- Absent
							at0.23]    -- Reduced
						}
					}
				}
			}
			allow_archetype CLUSTER[at0.8] occurrences matches {0..*} matches {    -- IX & X details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1|openEHR-EHR-CLUSTER\.exam-throat\.v0/}
			}
			ELEMENT[at0.18] occurrences matches {0..1} matches {    -- XI description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0.9] occurrences matches {0..*} matches {    -- XI details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1/}
			}
			ELEMENT[at0.19] occurrences matches {0..1} matches {    -- XII description
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0.10] occurrences matches {0..*} matches {    -- XII details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam\.v1|openEHR-EHR-CLUSTER\.exam-tongue\.v0/}
			}
		}
	}


ontology
	terminologies_available = <"SNOMED-CT", ...>
	term_definitions = <
		["en"] = <
			items = <
				["at0.1"] = <
					text = <"Cranial nerve">
					description = <"One of each of twelve pairs of nerves which arise directly from the brain.">
				>
				["at0.10"] = <
					text = <"XII details">
					description = <"Details about the function of the hypoglossal nerve.">
				>
				["at0.11"] = <
					text = <"I description">
					description = <"Narrative description about findings on examination of the olfactory nerve.">
					comment = <"For example: summary about smell testing.">
				>
				["at0.12"] = <
					text = <"II description">
					description = <"Narrative description about findings on examination of the optic nerve.">
				>
				["at0.13"] = <
					text = <"III, IV & VI description">
					description = <"Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.14"] = <
					text = <"V description">
					description = <"Narrative description about findings on examination of the trigeminal nerve.">
				>
				["at0.15"] = <
					text = <"VII description">
					description = <"Narrative description about findings on examination of the facial nerve.">
				>
				["at0.16"] = <
					text = <"VIII description">
					description = <"Narrative description about findings on examination of the vestibulococchlear nerve.">
				>
				["at0.17"] = <
					text = <"IX & X description">
					description = <"Narrative description about findings on examination of the glossopharyngeal and vagus nerves.">
				>
				["at0.18"] = <
					text = <"XI description">
					description = <"Narrative description about findings on examination of the accessory nerve.">
				>
				["at0.19"] = <
					text = <"XII description">
					description = <"Narrative description about findings on examination of the hypoglossal nerve.">
				>
				["at0.2"] = <
					text = <"I details">
					description = <"Details about function of the olfactory nerve.">
				>
				["at0.20"] = <
					text = <"Corneal reflex">
					description = <"The presence of the corneal reflex.">
					comment = <"Also known as the 'blink reflex'.">
				>
				["at0.21"] = <
					text = <"Present">
					description = <"The reflex is observed.">
				>
				["at0.22"] = <
					text = <"Absent">
					description = <"The reflex is not observed.">
				>
				["at0.23"] = <
					text = <"Reduced">
					description = <"The reflex is observed, but diminished compared to normal.">
				>
				["at0.24"] = <
					text = <"Jaw jerk">
					description = <"The presence of the jaw jerk.">
				>
				["at0.25"] = <
					text = <"Present">
					description = <"The jaw jerk is present.">
				>
				["at0.26"] = <
					text = <"Absent">
					description = <"The jaw jerk is absent.">
				>
				["at0.3"] = <
					text = <"II details">
					description = <"Details about the function of the optic nerve.">
				>
				["at0.4"] = <
					text = <"III, IV & VI details">
					description = <"Details about the function of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.5"] = <
					text = <"V details">
					description = <"Details about the function of the trigeminal nerve.">
				>
				["at0.6"] = <
					text = <"VII details">
					description = <"Details about the function of the facial nerve.">
				>
				["at0.7"] = <
					text = <"VIII details">
					description = <"Details about the function of the vestibulococchlear nerve.">
				>
				["at0.8"] = <
					text = <"IX & X details">
					description = <"Details about the function of the glossopharyngeal and vagus nerves.">
				>
				["at0.9"] = <
					text = <"XI details">
					description = <"Details about the function of the accessory nerve.">
				>
				["at0000.1"] = <
					text = <"Examination of cranial nerves">
					description = <"Findings observed during the physical examination of the cranial nerves.">
				>
				["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.">
				>
				["at0.27"] = <
					text = <"Gag reflex">
					description = <"The presence of the pharyngeal, or gag, reflex.">
				>
				["at0000"] = <
					text = <"Physical 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 = <"For example examination of a specific area of skin. 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 = <"*Cranial nerve (en)">
					description = <"*">
				>
				["at0.10"] = <
					text = <"*XII details (en)">
					description = <"*Details about the function of the hypoglossal nerve. (en)">
				>
				["at0.11"] = <
					text = <"*I description (en)">
					description = <"*Narrative description about findings on examination of the olfactory nerve. (en)">
					comment = <"*For example: summary about smell testing. (en)">
				>
				["at0.12"] = <
					text = <"*II description (en)">
					description = <"*Narrative description about findings on examination of the optic nerve. (en)">
				>
				["at0.13"] = <
					text = <"*III, IV & VI description (en)">
					description = <"*Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves. (en)">
				>
				["at0.14"] = <
					text = <"*V description (en)">
					description = <"*Narrative description about findings on examination of the trigeminal nerve. (en)">
				>
				["at0.15"] = <
					text = <"*VII description (en)">
					description = <"*Narrative description about findings on examination of the facial nerve. (en)">
				>
				["at0.16"] = <
					text = <"*VIII description (en)">
					description = <"*Narrative description about findings on examination of the vestibulococchlear nerve. (en)">
				>
				["at0.17"] = <
					text = <"*IX & X description (en)">
					description = <"*Narrative description about findings on examination of the glossopharyngeal and vagus nerves. (en)">
				>
				["at0.18"] = <
					text = <"*XI description (en)">
					description = <"*Narrative description about findings on examination of the accessory nerve. (en)">
				>
				["at0.19"] = <
					text = <"*XII description (en)">
					description = <"*Narrative description about findings on examination of the hypoglossal nerve. (en)">
				>
				["at0.2"] = <
					text = <"*I details (en)">
					description = <"*Details about function of the olfactory nerve. (en)">
				>
				["at0.20"] = <
					text = <"*Corneal reflex(en)">
					description = <"*The presence of the corneal reflex.(en)">
					comment = <"*Also known as the 'blink reflex'.(en)">
				>
				["at0.21"] = <
					text = <"*Present (en)">
					description = <"*The corneal reflex is present. (en)">
				>
				["at0.22"] = <
					text = <"*Absent (en)">
					description = <"*The corneal reflex is absent. (en)">
				>
				["at0.23"] = <
					text = <"*Reduced (en)">
					description = <"*The corneal reflex is present, but diminished compared to normal. (en)">
				>
				["at0.24"] = <
					text = <"*Jaw jerk(en)">
					description = <"*The presence of the jaw jerk.(en)">
				>
				["at0.25"] = <
					text = <"*Present (en)">
					description = <"*The jaw jerk is present. (en)">
				>
				["at0.26"] = <
					text = <"*Absent (en)">
					description = <"*The jaw jerk is absent. (en)">
				>
				["at0.3"] = <
					text = <"*II details (en)">
					description = <"*Details about the function of the optic nerve. (en)">
				>
				["at0.4"] = <
					text = <"*III, IV & VI details (en)">
					description = <"*Details about the function of the oculomotor, trochlear and abducens nerves. (en)">
				>
				["at0.5"] = <
					text = <"*V details (en)">
					description = <"*Details about the function of the trigeminal nerve. (en)">
				>
				["at0.6"] = <
					text = <"*VII details (en)">
					description = <"*Details about the function of the facial nerve. (en)">
				>
				["at0.7"] = <
					text = <"*VIII details (en)">
					description = <"*Details about the function of the vestibulococchlear nerve. (en)">
				>
				["at0.8"] = <
					text = <"*IX & X details (en)">
					description = <"*Details about the function of the glossopharyngeal and vagus nerves. (en)">
				>
				["at0.9"] = <
					text = <"*XI details (en)">
					description = <"*Details about the function of the accessory nerve. (en)">
				>
				["at0000.1"] = <
					text = <"*Examination of cranial nerves (en)">
					description = <"Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur.">
				>
				["at0001.1"] = <
					text = <"Undersøkt organsystem eller struktur">
					description = <"Identifisering av det undersøkte organsystemet eller anatomiske strukturen.">
					comment = <"Det er anbefalt å kode det undersøkte systemet eller strukturen med en terminologi, der det er mulig.">
				>
				["at0.27"] = <
					text = <"*Gag reflex (en)">
					description = <"*The presence of the pharyngeal, or gag, reflex. (en)">
				>
				["at0000"] = <
					text = <"Funn ved fysisk undersøkelse">
					description = <"Undersøkelsesfunn gjort 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 = <"For eksempel undersøkelse av et spesifikt område på huden. Dersom den anatomiske lokaliseringen allerede er identifisert i elementet \"Undersøkt organsystem eller struktur\" er dette dataelementet overflødig.">
				>
			>
		>
		["pt-br"] = <
			items = <
				["at0.1"] = <
					text = <"Cranial nerve">
					description = <"One of each of twelve pairs of nerves which arise directly from the brain.">
				>
				["at0.10"] = <
					text = <"XII details">
					description = <"Details about the function of the hypoglossal nerve.">
				>
				["at0.11"] = <
					text = <"I description">
					description = <"Narrative description about findings on examination of the olfactory nerve.">
					comment = <"For example: summary about smell testing.">
				>
				["at0.12"] = <
					text = <"II description">
					description = <"Narrative description about findings on examination of the optic nerve.">
				>
				["at0.13"] = <
					text = <"III, IV & VI description">
					description = <"Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.14"] = <
					text = <"V description">
					description = <"Narrative description about findings on examination of the trigeminal nerve.">
				>
				["at0.15"] = <
					text = <"VII description">
					description = <"Narrative description about findings on examination of the facial nerve.">
				>
				["at0.16"] = <
					text = <"VIII description">
					description = <"Narrative description about findings on examination of the vestibulococchlear nerve.">
				>
				["at0.17"] = <
					text = <"IX & X description">
					description = <"Narrative description about findings on examination of the glossopharyngeal and vagus nerves.">
				>
				["at0.18"] = <
					text = <"XI description">
					description = <"Narrative description about findings on examination of the accessory nerve.">
				>
				["at0.19"] = <
					text = <"XII description">
					description = <"Narrative description about findings on examination of the hypoglossal nerve.">
				>
				["at0.2"] = <
					text = <"I details">
					description = <"Details about function of the olfactory nerve.">
				>
				["at0.20"] = <
					text = <"Corneal reflex">
					description = <"The presence of the corneal reflex.">
					comment = <"Also known as the 'blink reflex'.">
				>
				["at0.21"] = <
					text = <"Present">
					description = <"The reflex is observed.">
				>
				["at0.22"] = <
					text = <"Absent">
					description = <"The reflex is not observed.">
				>
				["at0.23"] = <
					text = <"Reduced">
					description = <"The reflex is observed, but diminished compared to normal.">
				>
				["at0.24"] = <
					text = <"Jaw jerk">
					description = <"The presence of the jaw jerk.">
				>
				["at0.25"] = <
					text = <"Present">
					description = <"The jaw jerk is present.">
				>
				["at0.26"] = <
					text = <"Absent">
					description = <"The jaw jerk is absent.">
				>
				["at0.3"] = <
					text = <"II details">
					description = <"Details about the function of the optic nerve.">
				>
				["at0.4"] = <
					text = <"III, IV & VI details">
					description = <"Details about the function of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.5"] = <
					text = <"V details">
					description = <"Details about the function of the trigeminal nerve.">
				>
				["at0.6"] = <
					text = <"VII details">
					description = <"Details about the function of the facial nerve.">
				>
				["at0.7"] = <
					text = <"VIII details">
					description = <"Details about the function of the vestibulococchlear nerve.">
				>
				["at0.8"] = <
					text = <"IX & X details">
					description = <"Details about the function of the glossopharyngeal and vagus nerves.">
				>
				["at0.9"] = <
					text = <"XI details">
					description = <"Details about the function of the accessory nerve.">
				>
				["at0000.1"] = <
					text = <"*Physical examination findings (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.">
				>
				["at0.27"] = <
					text = <"Gag reflex">
					description = <"The presence of the pharyngeal, or gag, reflex.">
				>
				["at0000"] = <
					text = <"*Physical examination findings (en)">
					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 = <"*Identification of the area of the body under examination. (en)">
					comment = <"*For example examination of a specific area of skin. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant. (en)">
				>
			>
		>
		["de"] = <
			items = <
				["at0.1"] = <
					text = <"Cranial nerve">
					description = <"One of each of twelve pairs of nerves which arise directly from the brain.">
				>
				["at0.10"] = <
					text = <"XII details">
					description = <"Details about the function of the hypoglossal nerve.">
				>
				["at0.11"] = <
					text = <"I description">
					description = <"Narrative description about findings on examination of the olfactory nerve.">
					comment = <"For example: summary about smell testing.">
				>
				["at0.12"] = <
					text = <"II description">
					description = <"Narrative description about findings on examination of the optic nerve.">
				>
				["at0.13"] = <
					text = <"III, IV & VI description">
					description = <"Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.14"] = <
					text = <"V description">
					description = <"Narrative description about findings on examination of the trigeminal nerve.">
				>
				["at0.15"] = <
					text = <"VII description">
					description = <"Narrative description about findings on examination of the facial nerve.">
				>
				["at0.16"] = <
					text = <"VIII description">
					description = <"Narrative description about findings on examination of the vestibulococchlear nerve.">
				>
				["at0.17"] = <
					text = <"IX & X description">
					description = <"Narrative description about findings on examination of the glossopharyngeal and vagus nerves.">
				>
				["at0.18"] = <
					text = <"XI description">
					description = <"Narrative description about findings on examination of the accessory nerve.">
				>
				["at0.19"] = <
					text = <"XII description">
					description = <"Narrative description about findings on examination of the hypoglossal nerve.">
				>
				["at0.2"] = <
					text = <"I details">
					description = <"Details about function of the olfactory nerve.">
				>
				["at0.20"] = <
					text = <"Corneal reflex">
					description = <"The presence of the corneal reflex.">
					comment = <"Also known as the 'blink reflex'.">
				>
				["at0.21"] = <
					text = <"Present">
					description = <"The reflex is observed.">
				>
				["at0.22"] = <
					text = <"Absent">
					description = <"The reflex is not observed.">
				>
				["at0.23"] = <
					text = <"Reduced">
					description = <"The reflex is observed, but diminished compared to normal.">
				>
				["at0.24"] = <
					text = <"Jaw jerk">
					description = <"The presence of the jaw jerk.">
				>
				["at0.25"] = <
					text = <"Present">
					description = <"The jaw jerk is present.">
				>
				["at0.26"] = <
					text = <"Absent">
					description = <"The jaw jerk is absent.">
				>
				["at0.3"] = <
					text = <"II details">
					description = <"Details about the function of the optic nerve.">
				>
				["at0.4"] = <
					text = <"III, IV & VI details">
					description = <"Details about the function of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.5"] = <
					text = <"V details">
					description = <"Details about the function of the trigeminal nerve.">
				>
				["at0.6"] = <
					text = <"VII details">
					description = <"Details about the function of the facial nerve.">
				>
				["at0.7"] = <
					text = <"VIII details">
					description = <"Details about the function of the vestibulococchlear nerve.">
				>
				["at0.8"] = <
					text = <"IX & X details">
					description = <"Details about the function of the glossopharyngeal and vagus nerves.">
				>
				["at0.9"] = <
					text = <"XI details">
					description = <"Details about the function of the accessory nerve.">
				>
				["at0000.1"] = <
					text = <"Ergebnisse der körperlichen Untersuchung">
					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.">
				>
				["at0.27"] = <
					text = <"Gag reflex">
					description = <"The presence of the pharyngeal, or gag, reflex.">
				>
				["at0000"] = <
					text = <"Ergebnisse der körperlichen Untersuchung">
					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 = <"Zum Beispiel: „Ohne Befund“ oder „Mäßige Entzündung vorhanden“. Wenn möglich, wird die Codierung der „Klinischen Interpretation“ mit einer Terminologie 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 untersuchten Körperbereichs.">
					comment = <"Zum Beispiel die Untersuchung einer bestimmten Hautpartie. Wenn die Körperstelle im Datenelement „Untersuchtes System oder Struktur“ vollständig identifiziert wurde, wird dieses Datenelement überflüssig.">
				>
			>
		>
		["sv"] = <
			items = <
				["at0.1"] = <
					text = <"Cranial nerve">
					description = <"One of each of twelve pairs of nerves which arise directly from the brain.">
				>
				["at0.10"] = <
					text = <"XII details">
					description = <"Details about the function of the hypoglossal nerve.">
				>
				["at0.11"] = <
					text = <"I description">
					description = <"Narrative description about findings on examination of the olfactory nerve.">
					comment = <"For example: summary about smell testing.">
				>
				["at0.12"] = <
					text = <"II description">
					description = <"Narrative description about findings on examination of the optic nerve.">
				>
				["at0.13"] = <
					text = <"III, IV & VI description">
					description = <"Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.14"] = <
					text = <"V description">
					description = <"Narrative description about findings on examination of the trigeminal nerve.">
				>
				["at0.15"] = <
					text = <"VII description">
					description = <"Narrative description about findings on examination of the facial nerve.">
				>
				["at0.16"] = <
					text = <"VIII description">
					description = <"Narrative description about findings on examination of the vestibulococchlear nerve.">
				>
				["at0.17"] = <
					text = <"IX & X description">
					description = <"Narrative description about findings on examination of the glossopharyngeal and vagus nerves.">
				>
				["at0.18"] = <
					text = <"XI description">
					description = <"Narrative description about findings on examination of the accessory nerve.">
				>
				["at0.19"] = <
					text = <"XII description">
					description = <"Narrative description about findings on examination of the hypoglossal nerve.">
				>
				["at0.2"] = <
					text = <"I details">
					description = <"Details about function of the olfactory nerve.">
				>
				["at0.20"] = <
					text = <"Corneal reflex">
					description = <"The presence of the corneal reflex.">
					comment = <"Also known as the 'blink reflex'.">
				>
				["at0.21"] = <
					text = <"Present">
					description = <"The reflex is observed.">
				>
				["at0.22"] = <
					text = <"Absent">
					description = <"The reflex is not observed.">
				>
				["at0.23"] = <
					text = <"Reduced">
					description = <"The reflex is observed, but diminished compared to normal.">
				>
				["at0.24"] = <
					text = <"Jaw jerk">
					description = <"The presence of the jaw jerk.">
				>
				["at0.25"] = <
					text = <"Present">
					description = <"The jaw jerk is present.">
				>
				["at0.26"] = <
					text = <"Absent">
					description = <"The jaw jerk is absent.">
				>
				["at0.3"] = <
					text = <"II details">
					description = <"Details about the function of the optic nerve.">
				>
				["at0.4"] = <
					text = <"III, IV & VI details">
					description = <"Details about the function of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.5"] = <
					text = <"V details">
					description = <"Details about the function of the trigeminal nerve.">
				>
				["at0.6"] = <
					text = <"VII details">
					description = <"Details about the function of the facial nerve.">
				>
				["at0.7"] = <
					text = <"VIII details">
					description = <"Details about the function of the vestibulococchlear nerve.">
				>
				["at0.8"] = <
					text = <"IX & X details">
					description = <"Details about the function of the glossopharyngeal and vagus nerves.">
				>
				["at0.9"] = <
					text = <"XI details">
					description = <"Details about the function of the accessory nerve.">
				>
				["at0000.1"] = <
					text = <"*Physical examination findings (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.">
				>
				["at0.27"] = <
					text = <"Gag reflex">
					description = <"The presence of the pharyngeal, or gag, reflex.">
				>
				["at0000"] = <
					text = <"*Physical examination findings (en)">
					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 = <"*Identification of the area of the body under examination. (en)">
					comment = <"*For example examination of a specific area of skin. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant. (en)">
				>
			>
		>
		["el"] = <
			items = <
				["at0.1"] = <
					text = <"Cranial nerve">
					description = <"One of each of twelve pairs of nerves which arise directly from the brain.">
				>
				["at0.10"] = <
					text = <"XII details">
					description = <"Details about the function of the hypoglossal nerve.">
				>
				["at0.11"] = <
					text = <"I description">
					description = <"Narrative description about findings on examination of the olfactory nerve.">
					comment = <"For example: summary about smell testing.">
				>
				["at0.12"] = <
					text = <"II description">
					description = <"Narrative description about findings on examination of the optic nerve.">
				>
				["at0.13"] = <
					text = <"III, IV & VI description">
					description = <"Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.14"] = <
					text = <"V description">
					description = <"Narrative description about findings on examination of the trigeminal nerve.">
				>
				["at0.15"] = <
					text = <"VII description">
					description = <"Narrative description about findings on examination of the facial nerve.">
				>
				["at0.16"] = <
					text = <"VIII description">
					description = <"Narrative description about findings on examination of the vestibulococchlear nerve.">
				>
				["at0.17"] = <
					text = <"IX & X description">
					description = <"Narrative description about findings on examination of the glossopharyngeal and vagus nerves.">
				>
				["at0.18"] = <
					text = <"XI description">
					description = <"Narrative description about findings on examination of the accessory nerve.">
				>
				["at0.19"] = <
					text = <"XII description">
					description = <"Narrative description about findings on examination of the hypoglossal nerve.">
				>
				["at0.2"] = <
					text = <"I details">
					description = <"Details about function of the olfactory nerve.">
				>
				["at0.20"] = <
					text = <"Corneal reflex">
					description = <"The presence of the corneal reflex.">
					comment = <"Also known as the 'blink reflex'.">
				>
				["at0.21"] = <
					text = <"Present">
					description = <"The reflex is observed.">
				>
				["at0.22"] = <
					text = <"Absent">
					description = <"The reflex is not observed.">
				>
				["at0.23"] = <
					text = <"Reduced">
					description = <"The reflex is observed, but diminished compared to normal.">
				>
				["at0.24"] = <
					text = <"Jaw jerk">
					description = <"The presence of the jaw jerk.">
				>
				["at0.25"] = <
					text = <"Present">
					description = <"The jaw jerk is present.">
				>
				["at0.26"] = <
					text = <"Absent">
					description = <"The jaw jerk is absent.">
				>
				["at0.3"] = <
					text = <"II details">
					description = <"Details about the function of the optic nerve.">
				>
				["at0.4"] = <
					text = <"III, IV & VI details">
					description = <"Details about the function of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.5"] = <
					text = <"V details">
					description = <"Details about the function of the trigeminal nerve.">
				>
				["at0.6"] = <
					text = <"VII details">
					description = <"Details about the function of the facial nerve.">
				>
				["at0.7"] = <
					text = <"VIII details">
					description = <"Details about the function of the vestibulococchlear nerve.">
				>
				["at0.8"] = <
					text = <"IX & X details">
					description = <"Details about the function of the glossopharyngeal and vagus nerves.">
				>
				["at0.9"] = <
					text = <"XI details">
					description = <"Details about the function of the accessory nerve.">
				>
				["at0000.1"] = <
					text = <"*Physical examination findings (en)">
					description = <"Ευρήματα που παρατηρούνται κατά τη φυσική εξέταση ενός συστήματος σώματος ή ανατομικής δομής.">
				>
				["at0001.1"] = <
					text = <"Εξεταζόμενο σύστημα ή δομή">
					description = <"Ταυτοποίηση του εξεταζόμενου συστήματος σώματος ή ανατομικής δομής.">
					comment = <"Προτιμάται η κωδικοποίηση του συστήματος ή της δομής που εξετάζεται με ορολογία, όπου είναι δυνατόν.">
				>
				["at0.27"] = <
					text = <"Gag reflex">
					description = <"The presence of the pharyngeal, or gag, reflex.">
				>
				["at0000"] = <
					text = <"*Physical examination findings (en)">
					description = <"Ευρήματα που παρατηρούνται κατά τη φυσική εξέταση ενός συστήματος σώματος ή ανατομικής δομής.">
				>
				["at0001"] = <
					text = <"Εξεταζόμενο σύστημα ή δομή">
					description = <"Ταυτοποίηση του εξεταζόμενου συστήματος σώματος ή ανατομικής δομής.">
					comment = <"Προτιμάται η κωδικοποίηση του συστήματος ή της δομής που εξετάζεται με ορολογία, όπου είναι δυνατόν.">
				>
				["at0003"] = <
					text = <"Κλινική Περιγραφή">
					description = <"Αφηγηματική περιγραφή των συνολικών ευρημάτων που παρατηρήθηκαν κατά τη διάρκεια της φυσικής εξέτασης.">
				>
				["at0004"] = <
					text = <"Ευρήματα εξέτασης">
					description = <"Δομημένες λεπτομέρειες σχετικά με τα ευρήματα της φυσικής εξέτασης.">
				>
				["at0005"] = <
					text = <"Αναπαράσταση πολυμέσων">
					description = <"Ψηφιακή εικόνα, βίντεο ή διάγραμμα που αναπαριστά τα ευρήματα της φυσικής εξέτασης.">
				>
				["at0006"] = <
					text = <"Κλινική αξιολόγηση">
					description = <"Μία λέξη, φράση ή σύντομη περιγραφή που αντιπροσωπεύει την κλινική σημασία και σημασία των ευρημάτων της φυσικής εξέτασης.">
					comment = <"Για παράδειγμα: «Δεν ανιχνεύθηκε ανωμαλία» ή «Υπάρχει μέτρια φλεγμονή». Προτιμάται η κωδικοποίηση της «κλινικής ερμηνείας» με ορολογία, όπου είναι δυνατόν.">
				>
				["at0007"] = <
					text = <"Σχόλιο">
					description = <"Πρόσθετη αφήγηση σχετικά με τα ευρήματα της φυσικής εξέτασης, που δεν αποτυπώνεται σε άλλους τομείς.">
				>
				["at0008"] = <
					text = <"Λόγος διακοπής εξέτασης">
					description = <"Λεπτομέρειες για να καταγραφεί ρητά ότι αυτή η εξέταση δεν διενεργήθηκε.">
				>
				["at0011"] = <
					text = <"ω">
					description = <"περιγραφή της περιοχής του υπό εξέταση σώματος.">
					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.(en)">
				>
				["at0012"] = <
					text = <"Περιοχή σώματος">
					description = <"*Identification of the area of the body under examination. (en)">
					comment = <"*For example examination of a specific area of skin. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant. (en)">
				>
			>
		>
		["es"] = <
			items = <
				["at0.1"] = <
					text = <"Cranial nerve">
					description = <"One of each of twelve pairs of nerves which arise directly from the brain.">
				>
				["at0.10"] = <
					text = <"XII details">
					description = <"Details about the function of the hypoglossal nerve.">
				>
				["at0.11"] = <
					text = <"I description">
					description = <"Narrative description about findings on examination of the olfactory nerve.">
					comment = <"For example: summary about smell testing.">
				>
				["at0.12"] = <
					text = <"II description">
					description = <"Narrative description about findings on examination of the optic nerve.">
				>
				["at0.13"] = <
					text = <"III, IV & VI description">
					description = <"Narrative description about findings on examination of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.14"] = <
					text = <"V description">
					description = <"Narrative description about findings on examination of the trigeminal nerve.">
				>
				["at0.15"] = <
					text = <"VII description">
					description = <"Narrative description about findings on examination of the facial nerve.">
				>
				["at0.16"] = <
					text = <"VIII description">
					description = <"Narrative description about findings on examination of the vestibulococchlear nerve.">
				>
				["at0.17"] = <
					text = <"IX & X description">
					description = <"Narrative description about findings on examination of the glossopharyngeal and vagus nerves.">
				>
				["at0.18"] = <
					text = <"XI description">
					description = <"Narrative description about findings on examination of the accessory nerve.">
				>
				["at0.19"] = <
					text = <"XII description">
					description = <"Narrative description about findings on examination of the hypoglossal nerve.">
				>
				["at0.2"] = <
					text = <"I details">
					description = <"Details about function of the olfactory nerve.">
				>
				["at0.20"] = <
					text = <"Corneal reflex">
					description = <"The presence of the corneal reflex.">
					comment = <"Also known as the 'blink reflex'.">
				>
				["at0.21"] = <
					text = <"Present">
					description = <"The reflex is observed.">
				>
				["at0.22"] = <
					text = <"Absent">
					description = <"The reflex is not observed.">
				>
				["at0.23"] = <
					text = <"Reduced">
					description = <"The reflex is observed, but diminished compared to normal.">
				>
				["at0.24"] = <
					text = <"Jaw jerk">
					description = <"The presence of the jaw jerk.">
				>
				["at0.25"] = <
					text = <"Present">
					description = <"The jaw jerk is present.">
				>
				["at0.26"] = <
					text = <"Absent">
					description = <"The jaw jerk is absent.">
				>
				["at0.3"] = <
					text = <"II details">
					description = <"Details about the function of the optic nerve.">
				>
				["at0.4"] = <
					text = <"III, IV & VI details">
					description = <"Details about the function of the oculomotor, trochlear and abducens nerves.">
				>
				["at0.5"] = <
					text = <"V details">
					description = <"Details about the function of the trigeminal nerve.">
				>
				["at0.6"] = <
					text = <"VII details">
					description = <"Details about the function of the facial nerve.">
				>
				["at0.7"] = <
					text = <"VIII details">
					description = <"Details about the function of the vestibulococchlear nerve.">
				>
				["at0.8"] = <
					text = <"IX & X details">
					description = <"Details about the function of the glossopharyngeal and vagus nerves.">
				>
				["at0.9"] = <
					text = <"XI details">
					description = <"Details about the function of the accessory nerve.">
				>
				["at0000.1"] = <
					text = <"*Physical examination findings (en)">
					description = <"*Findings observed during the physical examination of a body system or anatomical structure.(en)">
				>
				["at0001.1"] = <
					text = <"*System or structure examined(en)">
					description = <"*Identification of the examined body system or anatomical structure.(en)">
					comment = <"*Coding of the system or structure examined with a terminology is preferred, where possible.(en)">
				>
				["at0.27"] = <
					text = <"Gag reflex">
					description = <"The presence of the pharyngeal, or gag, reflex.">
				>
				["at0000"] = <
					text = <"*Physical examination findings (en)">
					description = <"*Findings observed during the physical examination of a body system or anatomical structure.(en)">
				>
				["at0001"] = <
					text = <"*System or structure examined(en)">
					description = <"*Identification of the examined body system or anatomical structure.(en)">
					comment = <"*Coding of the system or structure examined with a terminology is preferred, where possible.(en)">
				>
				["at0003"] = <
					text = <"*Clinical description(en)">
					description = <"*Narrative description of the overall findings observed during the physical examination.(en)">
				>
				["at0004"] = <
					text = <"*Examination findings(en)">
					description = <"*Structured details about the physical examination findings.(en)">
				>
				["at0005"] = <
					text = <"*Multimedia representation(en)">
					description = <"*Digital image, video or diagram representing the physical examination findings.(en)">
				>
				["at0006"] = <
					text = <"*Clinical interpretation(en)">
					description = <"*Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.(en)">
					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 = <"*Comment(en)">
					description = <"*Additional narrative about the physical examination findings, not captured in other fields.(en)">
				>
				["at0008"] = <
					text = <"*Examination not done(en)">
					description = <"*Details to explicitly record that this examination was not performed.(en)">
				>
				["at0011"] = <
					text = <"*Structured body site(en)">
					description = <"*A structured description of the area of the body under examination.(en)">
					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.(en)">
				>
				["at0012"] = <
					text = <"*Body site(en)">
					description = <"*Identification of the area of the body under examination. (en)">
					comment = <"*For example examination of a specific area of skin. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant. (en)">
				>
			>
		>
	>
	term_bindings = <
		["SNOMED-CT"] = <
			items = <
				["at0.1"] = <[SNOMED-CT::25238003]>
			>
		>
	>