Modellbiblioteket openEHR Fork
Name
Examination of an external auditory canal
Description
Findings observed during the physical examination of an external auditory canal.
Purpose
To record a narrative description and clinical interpretation of the findings observed during the physical examination of an external auditory canal.
Use
Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of an external auditory canal.
This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-ear or OBSERVATION.exam archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate.
Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, the tympanic membrane.
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 CLUSTER.exam-ear or OBSERVATION.exam archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate.
Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, the tympanic membrane.
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 data not related to other parts of the ear or middle ear - use the specific archetypes, CLUSTER.exam-ear and CLUSTER.exam-middle_ear for this purpose.
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 clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
References
Derived from: Examination of external auditory canal, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2012 Sep 03. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1384_2 (discontinued).
Direct communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program.
Archetype Id
openEHR-EHR-CLUSTER.exam-external_auditory_canal.v0
Copyright
© Northern Territory Department of Health (Australia), 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
To record a narrative description and clinical interpretation of the findings observed during the physical examination of an external auditory canal.
| Language | Details |
|---|---|
| German |
Nina Schewe
Medizinische Hochschule Hannover
|
| Swedish |
Erik Sundvall
Region Östergötland + Linköping University
|
| Norwegian Bokmal |
Silje Ljosland Bakke
Nasjonal IKT HF
|
| Portuguese (Brazil) |
Adriana Kitajima
Hospital Alemão Oswaldo Cruz - HAOC
|
| Name | Card | Type | Description |
|---|---|---|---|
|
System or structure examined
|
1..1 | DV_CODED_TEXT |
Identification of the examined body system or anatomical structure.
Comment
Coding of the system or structure examined with a terminology is preferred, where possible.
Constraint for DV_CODED_TEXT
|
|
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
|
|
Wax description
|
0..1 | DV_TEXT |
Narrative description of the wax findings in the external auditory canal.
|
|
Canal tenderness
|
0..1 | DV_CODED_TEXT |
Presence of tenderness in the external auditory canal.
Constraint for DV_CODED_TEXT
|
|
Offensive odour
|
0..1 | DV_CODED_TEXT |
Presence of any offensive odour originating from the external auditory canal.
Constraint for DV_CODED_TEXT
|
|
Discharge presence
|
0..1 | DV_CODED_TEXT |
Presence of a discharge observed in the external auditory canal.
Constraint for DV_CODED_TEXT
|
|
Discharge type
|
0..1 | DV_CODED_TEXT |
Type of discharge observed in the external auditory canal or at the tympanic membrane.
Constraint for DV_CODED_TEXT
|
|
Discharge amount
|
0..1 | DV_CODED_TEXT |
Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane perforation.
Constraint for DV_CODED_TEXT
|
|
Discharge description
|
0..1 | DV_TEXT |
Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation.
|
|
Foreign body presence
|
0..1 | DV_CODED_TEXT |
Presence of a foreign body in the external auditory canal.
Constraint for DV_CODED_TEXT
|
|
Foreign body location
|
0..1 | DV_CODED_TEXT |
Location of the foreign body within the external auditory canal.
Comment
This data element is redundant if a foreign body is absent from the canal.
Constraint for DV_CODED_TEXT
|
archetype (adl_version=1.4; uid=bafa07d9-193a-4f46-be0f-0d1c78553329) openEHR-EHR-CLUSTER.exam-external_auditory_canal.v0 specialise openEHR-EHR-CLUSTER.exam.v2 concept [at0000.1] -- Examination of an external auditory canal language original_language = <[ISO_639-1::en]> translations = < ["de"] = < language = <[ISO_639-1::de]> author = < ["name"] = <"Nina Schewe"> ["organisation"] = <"Medizinische Hochschule Hannover"> ["email"] = <"schewe.nina@mh-hannover.de"> > > ["sv"] = < language = <[ISO_639-1::sv]> author = < ["name"] = <"Erik Sundvall"> ["organisation"] = <"Region Östergötland + Linköping University"> ["email"] = <"erik.sundvall@regionostergotland.se"> > > ["nb"] = < language = <[ISO_639-1::nb]> author = < ["name"] = <"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"> > > > description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Atomica Informatics"> ["email"] = <"heather.leslie@atomicainformatics.com"> ["date"] = <"2012-09-03"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"*To record the findings observed during the physical examination of a body system or anatomical structure. (en)"> use = <"*Use to record the observed findings during the physical examination of a body system or anatomical structure. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the \"Procedure detail\" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Specialisations of this archetype can be used to record examination findings for identified body systems or anatomical structures. If there is no appropriate specialisation available, use this archetype and identify the system or structure being examined using the 'System or structure examined' data element and the location on the body using the 'Body site' data element or the 'Structured body site' SLOT. Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. (en)"> 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)"> > ["sv"] = < language = <[ISO_639-1::sv]> purpose = <"*To record the findings observed during the physical examination of a body system or anatomical structure. (en)"> use = <"*Use to record the observed findings during the physical examination of a body system or anatomical structure. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the \"Procedure detail\" SLOT within the ACTION.procedure archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Specialisations of this archetype can be used to record examination findings for identified body systems or anatomical structures. If there is no appropriate specialisation available, use this archetype and identify the system or structure being examined using the 'System or structure examined' data element and the location on the body using the 'Body site' data element or the 'Structured body site' SLOT. Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. (en)"> keywords = <"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 can be used to record examination findings for identified body systems or anatomical structures. If there is no appropriate specialisation available, use this archetype and identify the system or structure being examined using the 'System or structure examined' data element and the location on the body using the 'Body site' data element or the 'Structured body site' SLOT. Interpretation of the findings, for example 'No abnormality detected' or 'Moderate inflammation present', can be recorded using the 'Clinical interpretation' data element. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. (en)"> 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 an external auditory canal."> use = <"Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of an external auditory canal. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-ear or OBSERVATION.exam archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, the tympanic membrane. 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 data not related to other parts of the ear or middle ear - use the specific archetypes, CLUSTER.exam-ear and CLUSTER.exam-middle_ear for this purpose. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign."> copyright = <"© Northern Territory Department of Health (Australia), 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"> ["references"] = <"Derived from: Examination of external auditory canal, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2012 Sep 03. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1384_2 (discontinued). Direct communication with clinical domain experts associated with Australia's Northern Territory Hearing Health Program."> ["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"] = <"A3A44541D87D10016792C346642E3316"> ["build_uid"] = <"e2588709-2581-4b18-ad76-1b1b92fa4534"> ["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 an external auditory canal items cardinality matches {1..*; unordered} matches { ELEMENT[at0001.1] matches { -- System or structure examined value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.1, -- Left external auditory canal at0.2] -- Right external auditory canal } } } } 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[at0004.1] occurrences matches {0..*} matches { -- Examination findings include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exam-tympanic_membrane\.v0|openEHR-EHR-CLUSTER\.exam-middle_ear\.v0/} } 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[at0.3] occurrences matches {0..1} matches { -- Wax description value matches { DV_TEXT matches {*} } } ELEMENT[at0.4] occurrences matches {0..1} matches { -- Canal tenderness value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.5, -- Present at0.6] -- Absent } } } } ELEMENT[at0.7] occurrences matches {0..1} matches { -- Offensive odour value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.8, -- Present at0.9] -- Absent } } } } ELEMENT[at0.10] occurrences matches {0..1} matches { -- Discharge presence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.11, -- Present at0.12] -- Absent } } } } ELEMENT[at0.13] occurrences matches {0..1} matches { -- Discharge type value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.14, -- Blood-stained at0.15, -- Haemoserous at0.16, -- Mucoid at0.17, -- Mucopurulent at0.18, -- Purulent at0.19] -- Serous } } } } ELEMENT[at0.20] occurrences matches {0..1} matches { -- Discharge amount value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.21, -- Scant at0.22, -- Moderate at0.23] -- Profuse } } } } ELEMENT[at0.24] occurrences matches {0..1} matches { -- Discharge description value matches { DV_TEXT matches {*} } } ELEMENT[at0.25] occurrences matches {0..1} matches { -- Foreign body presence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.26, -- Present at0.27] -- Absent } } } } ELEMENT[at0.28] occurrences matches {0..1} matches { -- Foreign body location value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.29, -- Outer canal at0.30, -- Deep canal at0.31] -- Middle ear } } } } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["en"] = < items = < ["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."> > ["at0000.1"] = < text = <"Examination of an external auditory canal"> description = <"Findings observed during the physical examination of an external auditory canal."> > ["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."> > ["at0.1"] = < text = <"Left external auditory canal"> description = <"The left auditory canal was examined."> > ["at0.2"] = < text = <"Right external auditory canal"> description = <"The right auditory canal was examined."> > ["at0.3"] = < text = <"Wax description"> description = <"Narrative description of the wax findings in the external auditory canal."> > ["at0.4"] = < text = <"Canal tenderness"> description = <"Presence of tenderness in the external auditory canal."> > ["at0.5"] = < text = <"Present"> description = <"Tenderness is noted in the external auditory canal wall."> > ["at0.6"] = < text = <"Absent"> description = <"Tenderness is not noted in the external auditory canal wall."> > ["at0.7"] = < text = <"Offensive odour"> description = <"Presence of any offensive odour originating from the external auditory canal."> > ["at0.8"] = < text = <"Present"> description = <"An offensive odour is noted as originating from the external auditory canal."> > ["at0.9"] = < text = <"Absent"> description = <"No offensive odour is noted as originating from the external auditory canal."> > ["at0.10"] = < text = <"Discharge presence"> description = <"Presence of a discharge observed in the external auditory canal."> > ["at0.11"] = < text = <"Present"> description = <"Discharge is observed within the external auditory canal."> > ["at0.12"] = < text = <"Absent"> description = <"Discharge is not observed within the external auditory canal."> > ["at0.13"] = < text = <"Discharge type"> description = <"Type of discharge observed in the external auditory canal or at the tympanic membrane."> > ["at0.14"] = < text = <"Blood-stained"> description = <"The discharge appears to consist mostly of blood."> > ["at0.15"] = < text = <"Haemoserous"> description = <"The discharge appears to consist of both blood and clear, watery fluid."> > ["at0.16"] = < text = <"Mucoid"> description = <"The discharge appears to consist mostly of a thick, mucoid substance."> > ["at0.17"] = < text = <"Mucopurulent"> description = <"The discharge appears to consist of both mucous and pus."> > ["at0.18"] = < text = <"Purulent"> description = <"The discharge appears to consist mostly of pus."> > ["at0.19"] = < text = <"Serous"> description = <"The discharge appears to consist mostly of clear, watery fluid."> > ["at0.20"] = < text = <"Discharge amount"> description = <"Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.21"] = < text = <"Scant"> description = <"A small amount of discharge is observed in the external auditory canal."> > ["at0.22"] = < text = <"Moderate"> description = <"A moderate amount of discharge is observed in the external auditory canal."> > ["at0.23"] = < text = <"Profuse"> description = <"A profuse amount of discharge is observed in the external auditory canal."> > ["at0.24"] = < text = <"Discharge description"> description = <"Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.25"] = < text = <"Foreign body presence"> description = <"Presence of a foreign body in the external auditory canal."> > ["at0.26"] = < text = <"Present"> description = <"A foreign body is present in the external auditory canal."> > ["at0.27"] = < text = <"Absent"> description = <"A foreign body is not present in the external auditory canal."> > ["at0.28"] = < text = <"Foreign body location"> description = <"Location of the foreign body within the external auditory canal."> comment = <"This data element is redundant if a foreign body is absent from the canal."> > ["at0.29"] = < text = <"Outer canal"> description = <"The foreign body is located in the outer part of the external auditory canal."> > ["at0.30"] = < text = <"Deep canal"> description = <"The foreign body is located in the deep, inner part of the external auditory canal."> > ["at0.31"] = < text = <"Middle ear"> description = <"The foreign body is located within the middle ear cavity."> > ["at0004.1"] = < text = <"Examination findings"> description = <"Structured details about the physical examination findings."> > ["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."> > ["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 = < ["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."> > ["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."> > ["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."> > ["at0000.1"] = < text = <"*Examination of an external auditory canal (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 = <"*Coding of the system or structure examined with a terminology is preferred, where possible. (en)"> > ["at0.1"] = < text = <"*Left auditory canal (en)"> description = <"*The left auditory canal was examined. (en)"> > ["at0.2"] = < text = <"*Right auditory canal (en)"> description = <"*The right auditory canal was examined. (en)"> > ["at0.3"] = < text = <"*Wax description (en)"> description = <"*Narrative description of the wax findings in the external auditory canal. (en)"> > ["at0.4"] = < text = <"*Canal tenderness (en)"> description = <"*Presence of tenderness in the external auditory canal. (en)"> > ["at0.5"] = < text = <"*Present (en)"> description = <"*Tenderness is noted in the external auditory canal wall. (en)"> > ["at0.6"] = < text = <"*Absent (en)"> description = <"*Tenderness is not noted in the external auditory canal wall. (en)"> > ["at0.7"] = < text = <"*Offensive odour (en)"> description = <"*Presence of any offensive odour originating from the external auditory canal. (en)"> > ["at0.8"] = < text = <"*Present (en)"> description = <"*An offensive odour is noted as originating from the external auditory canal. (en)"> > ["at0.9"] = < text = <"*Absent (en)"> description = <"*No offensive odour is noted as originating from the external auditory canal. (en)"> > ["at0.10"] = < text = <"*Discharge presence (en)"> description = <"*Presence of a discharge observed in the external auditory canal. (en)"> > ["at0.11"] = < text = <"*Present (en)"> description = <"*Discharge is observed within the external auditory canal. (en)"> > ["at0.12"] = < text = <"*Absent (en)"> description = <"*Discharge is not observed within the external auditory canal. (en)"> > ["at0.13"] = < text = <"*Discharge type (en)"> description = <"*Type of discharge observed in the external auditory canal or at the tympanic membrane. (en)"> > ["at0.14"] = < text = <"*Blood-stained (en)"> description = <"*The discharge appears to consist mostly of blood. (en)"> > ["at0.15"] = < text = <"*Haemoserous (en)"> description = <"*The discharge appears to consist of both blood and clear, watery fluid. (en)"> > ["at0.16"] = < text = <"*Mucoid (en)"> description = <"*The discharge appears to consist mostly of a thick, mucoid substance. (en)"> > ["at0.17"] = < text = <"*Mucopurulent (en)"> description = <"*The discharge appears to consist of both mucous and pus. (en)"> > ["at0.18"] = < text = <"*Purulent (en)"> description = <"*The discharge appears to consist mostly of pus. (en)"> > ["at0.19"] = < text = <"*Serous (en)"> description = <"*The discharge appears to consist mostly of clear, watery fluid. (en)"> > ["at0.20"] = < text = <"*Discharge amount (en)"> description = <"*Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane perforation. (en)"> > ["at0.21"] = < text = <"*Scant (en)"> description = <"*A small amount of discharge is observed in the external auditory canal. (en)"> > ["at0.22"] = < text = <"*Moderate (en)"> description = <"*A moderate amount of discharge is observed in the external auditory canal. (en)"> > ["at0.23"] = < text = <"*Profuse (en)"> description = <"*A profuse amount of discharge is observed in the external auditory canal. (en)"> > ["at0.24"] = < text = <"*Discharge description (en)"> description = <"*Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation. (en)"> > ["at0.25"] = < text = <"*Foreign body presence (en)"> description = <"*Presence of a foreign body in the external auditory canal. (en)"> > ["at0.26"] = < text = <"*Present (en)"> description = <"*A foreign body is present in the external auditory canal. (en)"> > ["at0.27"] = < text = <"*Absent (en)"> description = <"*A foreign body is not present in the external auditory canal. (en)"> > ["at0.28"] = < text = <"*Foreign body location (en)"> description = <"*Location of the foreign body within the external auditory canal. (en)"> comment = <"*This data element is redundant if a foreign body is absent from the canal. (en)"> > ["at0.29"] = < text = <"*Outer canal (en)"> description = <"*The foreign body is located in the outer part of the external auditory canal. (en)"> > ["at0.30"] = < text = <"*Deep canal (en)"> description = <"*The foreign body is located in the deep, inner part of the external auditory canal. (en)"> > ["at0.31"] = < text = <"*Middle ear (en)"> description = <"*The foreign body is located within the middle ear cavity. (en)"> > ["at0004.1"] = < text = <"Spesifikke funn"> description = <"Ytterligere strukturerte detaljer om undersøkelsesfunnene."> > ["at0000"] = < text = <"Undersøkelsesfunn"> description = <"Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur."> > ["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."> > ["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."> > > > ["pt-br"] = < items = < ["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)"> > ["at0000.1"] = < text = <"Resultados do exame"> 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."> > ["at0.1"] = < text = <"Left external auditory canal"> description = <"The left auditory canal was examined."> > ["at0.2"] = < text = <"Right external auditory canal"> description = <"The right auditory canal was examined."> > ["at0.3"] = < text = <"Wax description"> description = <"Narrative description of the wax findings in the external auditory canal."> > ["at0.4"] = < text = <"Canal tenderness"> description = <"Presence of tenderness in the external auditory canal."> > ["at0.5"] = < text = <"Present"> description = <"Tenderness is noted in the external auditory canal wall."> > ["at0.6"] = < text = <"Absent"> description = <"Tenderness is not noted in the external auditory canal wall."> > ["at0.7"] = < text = <"Offensive odour"> description = <"Presence of any offensive odour originating from the external auditory canal."> > ["at0.8"] = < text = <"Present"> description = <"An offensive odour is noted as originating from the external auditory canal."> > ["at0.9"] = < text = <"Absent"> description = <"No offensive odour is noted as originating from the external auditory canal."> > ["at0.10"] = < text = <"Discharge presence"> description = <"Presence of a discharge observed in the external auditory canal."> > ["at0.11"] = < text = <"Present"> description = <"Discharge is observed within the external auditory canal."> > ["at0.12"] = < text = <"Absent"> description = <"Discharge is not observed within the external auditory canal."> > ["at0.13"] = < text = <"Discharge type"> description = <"Type of discharge observed in the external auditory canal or at the tympanic membrane."> > ["at0.14"] = < text = <"Blood-stained"> description = <"The discharge appears to consist mostly of blood."> > ["at0.15"] = < text = <"Haemoserous"> description = <"The discharge appears to consist of both blood and clear, watery fluid."> > ["at0.16"] = < text = <"Mucoid"> description = <"The discharge appears to consist mostly of a thick, mucoid substance."> > ["at0.17"] = < text = <"Mucopurulent"> description = <"The discharge appears to consist of both mucous and pus."> > ["at0.18"] = < text = <"Purulent"> description = <"The discharge appears to consist mostly of pus."> > ["at0.19"] = < text = <"Serous"> description = <"The discharge appears to consist mostly of clear, watery fluid."> > ["at0.20"] = < text = <"Discharge amount"> description = <"Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.21"] = < text = <"Scant"> description = <"A small amount of discharge is observed in the external auditory canal."> > ["at0.22"] = < text = <"Moderate"> description = <"A moderate amount of discharge is observed in the external auditory canal."> > ["at0.23"] = < text = <"Profuse"> description = <"A profuse amount of discharge is observed in the external auditory canal."> > ["at0.24"] = < text = <"Discharge description"> description = <"Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.25"] = < text = <"Foreign body presence"> description = <"Presence of a foreign body in the external auditory canal."> > ["at0.26"] = < text = <"Present"> description = <"A foreign body is present in the external auditory canal."> > ["at0.27"] = < text = <"Absent"> description = <"A foreign body is not present in the external auditory canal."> > ["at0.28"] = < text = <"Foreign body location"> description = <"Location of the foreign body within the external auditory canal."> comment = <"This data element is redundant if a foreign body is absent from the canal."> > ["at0.29"] = < text = <"Outer canal"> description = <"The foreign body is located in the outer part of the external auditory canal."> > ["at0.30"] = < text = <"Deep canal"> description = <"The foreign body is located in the deep, inner part of the external auditory canal."> > ["at0.31"] = < text = <"Middle ear"> description = <"The foreign body is located within the middle ear cavity."> > ["at0004.1"] = < text = <"Resultados do exame"> description = <"Detalhes estruturados sobre os resultados do exame físico."> > ["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."> > ["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 = < ["at0006"] = < text = <"Klinische Interpretation"> description = <"Ein einzelnes Wort, eine Phrase oder eine kurze Beschreibung, die die klinische Bedeutung und Wichtigkeit der Untersuchungsergebnisse darstellt."> comment = <"*For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. (en)"> > ["at0000.1"] = < text = <"Untersuchungsergebnisse"> 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."> > ["at0.1"] = < text = <"Left external auditory canal"> description = <"The left auditory canal was examined."> > ["at0.2"] = < text = <"Right external auditory canal"> description = <"The right auditory canal was examined."> > ["at0.3"] = < text = <"Wax description"> description = <"Narrative description of the wax findings in the external auditory canal."> > ["at0.4"] = < text = <"Canal tenderness"> description = <"Presence of tenderness in the external auditory canal."> > ["at0.5"] = < text = <"Present"> description = <"Tenderness is noted in the external auditory canal wall."> > ["at0.6"] = < text = <"Absent"> description = <"Tenderness is not noted in the external auditory canal wall."> > ["at0.7"] = < text = <"Offensive odour"> description = <"Presence of any offensive odour originating from the external auditory canal."> > ["at0.8"] = < text = <"Present"> description = <"An offensive odour is noted as originating from the external auditory canal."> > ["at0.9"] = < text = <"Absent"> description = <"No offensive odour is noted as originating from the external auditory canal."> > ["at0.10"] = < text = <"Discharge presence"> description = <"Presence of a discharge observed in the external auditory canal."> > ["at0.11"] = < text = <"Present"> description = <"Discharge is observed within the external auditory canal."> > ["at0.12"] = < text = <"Absent"> description = <"Discharge is not observed within the external auditory canal."> > ["at0.13"] = < text = <"Discharge type"> description = <"Type of discharge observed in the external auditory canal or at the tympanic membrane."> > ["at0.14"] = < text = <"Blood-stained"> description = <"The discharge appears to consist mostly of blood."> > ["at0.15"] = < text = <"Haemoserous"> description = <"The discharge appears to consist of both blood and clear, watery fluid."> > ["at0.16"] = < text = <"Mucoid"> description = <"The discharge appears to consist mostly of a thick, mucoid substance."> > ["at0.17"] = < text = <"Mucopurulent"> description = <"The discharge appears to consist of both mucous and pus."> > ["at0.18"] = < text = <"Purulent"> description = <"The discharge appears to consist mostly of pus."> > ["at0.19"] = < text = <"Serous"> description = <"The discharge appears to consist mostly of clear, watery fluid."> > ["at0.20"] = < text = <"Discharge amount"> description = <"Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.21"] = < text = <"Scant"> description = <"A small amount of discharge is observed in the external auditory canal."> > ["at0.22"] = < text = <"Moderate"> description = <"A moderate amount of discharge is observed in the external auditory canal."> > ["at0.23"] = < text = <"Profuse"> description = <"A profuse amount of discharge is observed in the external auditory canal."> > ["at0.24"] = < text = <"Discharge description"> description = <"Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.25"] = < text = <"Foreign body presence"> description = <"Presence of a foreign body in the external auditory canal."> > ["at0.26"] = < text = <"Present"> description = <"A foreign body is present in the external auditory canal."> > ["at0.27"] = < text = <"Absent"> description = <"A foreign body is not present in the external auditory canal."> > ["at0.28"] = < text = <"Foreign body location"> description = <"Location of the foreign body within the external auditory canal."> comment = <"This data element is redundant if a foreign body is absent from the canal."> > ["at0.29"] = < text = <"Outer canal"> description = <"The foreign body is located in the outer part of the external auditory canal."> > ["at0.30"] = < text = <"Deep canal"> description = <"The foreign body is located in the deep, inner part of the external auditory canal."> > ["at0.31"] = < text = <"Middle ear"> description = <"The foreign body is located within the middle ear cavity."> > ["at0004.1"] = < text = <"Untersuchungsergebnisse"> description = <"Strukturierte Angaben zu den Ergebnissen der körperlichen Untersuchung."> > ["at0000"] = < text = <"Untersuchungsergebnisse"> description = <"Während der körperlichen Untersuchung eines Körpersystems oder einer anatomischen Struktur beobachtete Befunde."> > ["at0001"] = < text = <"Untersuchtes System oder untersuchte Struktur"> description = <"Identifizierung des untersuchten Körpersystems oder der anatomischen Struktur."> comment = <"Wenn möglich wird die Kodierung des untersuchten Systems oder der untersuchten Struktur mit einer Terminologie bevorzugt."> > ["at0003"] = < text = <"Klinische Beschreibung"> description = <"Beschreibung der bei der körperlichen Untersuchung beobachteten Gesamtbefunde."> > ["at0004"] = < text = <"Untersuchungsergebnisse"> description = <"Strukturierte Angaben zu den Ergebnissen der körperlichen Untersuchung."> > ["at0005"] = < text = <"Multimediale Darstellung"> description = <"Digitales Bild, Video oder Diagramm, das die Ergebnisse der körperlichen Untersuchung darstellt."> > ["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 = < ["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)"> > ["at0000.1"] = < text = <"Fynd vid undersökning"> 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."> > ["at0.1"] = < text = <"Left external auditory canal"> description = <"The left auditory canal was examined."> > ["at0.2"] = < text = <"Right external auditory canal"> description = <"The right auditory canal was examined."> > ["at0.3"] = < text = <"Wax description"> description = <"Narrative description of the wax findings in the external auditory canal."> > ["at0.4"] = < text = <"Canal tenderness"> description = <"Presence of tenderness in the external auditory canal."> > ["at0.5"] = < text = <"Present"> description = <"Tenderness is noted in the external auditory canal wall."> > ["at0.6"] = < text = <"Absent"> description = <"Tenderness is not noted in the external auditory canal wall."> > ["at0.7"] = < text = <"Offensive odour"> description = <"Presence of any offensive odour originating from the external auditory canal."> > ["at0.8"] = < text = <"Present"> description = <"An offensive odour is noted as originating from the external auditory canal."> > ["at0.9"] = < text = <"Absent"> description = <"No offensive odour is noted as originating from the external auditory canal."> > ["at0.10"] = < text = <"Discharge presence"> description = <"Presence of a discharge observed in the external auditory canal."> > ["at0.11"] = < text = <"Present"> description = <"Discharge is observed within the external auditory canal."> > ["at0.12"] = < text = <"Absent"> description = <"Discharge is not observed within the external auditory canal."> > ["at0.13"] = < text = <"Discharge type"> description = <"Type of discharge observed in the external auditory canal or at the tympanic membrane."> > ["at0.14"] = < text = <"Blood-stained"> description = <"The discharge appears to consist mostly of blood."> > ["at0.15"] = < text = <"Haemoserous"> description = <"The discharge appears to consist of both blood and clear, watery fluid."> > ["at0.16"] = < text = <"Mucoid"> description = <"The discharge appears to consist mostly of a thick, mucoid substance."> > ["at0.17"] = < text = <"Mucopurulent"> description = <"The discharge appears to consist of both mucous and pus."> > ["at0.18"] = < text = <"Purulent"> description = <"The discharge appears to consist mostly of pus."> > ["at0.19"] = < text = <"Serous"> description = <"The discharge appears to consist mostly of clear, watery fluid."> > ["at0.20"] = < text = <"Discharge amount"> description = <"Qualitative amount of discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.21"] = < text = <"Scant"> description = <"A small amount of discharge is observed in the external auditory canal."> > ["at0.22"] = < text = <"Moderate"> description = <"A moderate amount of discharge is observed in the external auditory canal."> > ["at0.23"] = < text = <"Profuse"> description = <"A profuse amount of discharge is observed in the external auditory canal."> > ["at0.24"] = < text = <"Discharge description"> description = <"Narrative description of the discharge observed in the external auditory canal or at the tympanic membrane perforation."> > ["at0.25"] = < text = <"Foreign body presence"> description = <"Presence of a foreign body in the external auditory canal."> > ["at0.26"] = < text = <"Present"> description = <"A foreign body is present in the external auditory canal."> > ["at0.27"] = < text = <"Absent"> description = <"A foreign body is not present in the external auditory canal."> > ["at0.28"] = < text = <"Foreign body location"> description = <"Location of the foreign body within the external auditory canal."> comment = <"This data element is redundant if a foreign body is absent from the canal."> > ["at0.29"] = < text = <"Outer canal"> description = <"The foreign body is located in the outer part of the external auditory canal."> > ["at0.30"] = < text = <"Deep canal"> description = <"The foreign body is located in the deep, inner part of the external auditory canal."> > ["at0.31"] = < text = <"Middle ear"> description = <"The foreign body is located within the middle ear cavity."> > ["at0004.1"] = < text = <"Fynd vid undersökning"> description = <"Strukturerade detaljer om fynd vid den fysiska undersökningen."> > ["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."> > ["at0007"] = < text = <"Kommentar"> description = <"Kommentarer avseende undersökningsfynd som inte beskrivs i övriga fält."> > ["at0008"] = < text = <"Undersökning ej genomförd"> description = <"Detaljerad beskrivning om att undersökningen inte genomfördes."> > ["at0011"] = < text = <"Strukturerad anatomisk plats"> description = <"Strukturerad beskrivning av den anatomiska platsen som undersökts."> comment = <"Om den anatomiska platsen kan identifieras helt via dataelementet \"System eller struktur som undersökts\" så blir denna del redundant."> > ["at0012"] = < text = <"Anatomisk plats"> description = <"Identifiering av den anatomiska plats som undersökts. "> comment = <"Om den anatomiska platsen har identifierats fullt ut i \"System eller struktur som undersökts\" så blir detta element redundant. "> > > > > term_bindings = < ["SNOMED-CT"] = < items = < ["at0.1"] = <[SNOMED-CT::71471005]> ["at0.2"] = <[SNOMED-CT::45124007]> ["at0000"] = <[SNOMED-CT::5880005]> > > >