archetype (adl_version=1.4; uid=62289e06-ca9c-4dc9-8b51-23640759d553)
	openEHR-EHR-CLUSTER.exam-palpation-prostate.v0
specialise
	openEHR-EHR-CLUSTER.exam-palpation.v0

concept
	[at0000.1.1]	-- Palpation of the prostate
language
	original_language = <[ISO_639-1::en]>
	translations = <
		["nb"] = <
			language = <[ISO_639-1::nb]>
			author = <
				["name"] = <"Silje Ljosland Bakke">
				["organisation"] = <"Nasjonal IKT HF">
			>
		>
	>
description
	original_author = <
		["name"] = <"Heather Leslie">
		["organisation"] = <"Atomica Informatics">
		["email"] = <"heather.leslie@atomicainformatics.com">
		["date"] = <"2015-09-17">
	>
	details = <
		["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.">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To record a narrative description and clinical interpretation of the findings observed only by palpation of the prostate.">
			use = <"Use to record a narrative description and clinical interpretation of the findings observed only by palpation of the prostate.

This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-palpation-rectum or OBSERVATION.exam archetypes, 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.

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 when multiple modes are used simultaneously to examine a body system or anatomical structure, including inspection or auscultation. Use the CLUSTER.exam family of archetypes 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 = <"© 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)", "Anca Heyd, DIPS ASA, Norway">
	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"] = <"3FE51F4BCA534CA5D6BE8120A203DCE4">
		["build_uid"] = <"6a0a4923-4360-47a0-8a38-b32b91688427">
		["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[at0000.1.1] matches {    -- Palpation of the prostate
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0001.0.1] matches {    -- System or structure examined
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::at0.0.1]    -- Prostate
						}
					}
				}
			}
			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_]+)*\.v1/}
			}
			ELEMENT[at0002] occurrences matches {0..1} matches {    -- No abnormality detected
				value matches {
					DV_BOOLEAN matches {
						value matches {true}
					}
				}
			}
			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\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0/}
			}
			ELEMENT[at0006] occurrences matches {0..*} matches {    -- Clinical interpretation
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0007] occurrences matches {0..1} matches {    -- Comment
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches {    -- Examination not done
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/}
			}
		}
	}


ontology
	terminologies_available = <"SNOMED-CT", ...>
	term_definitions = <
		["en"] = <
			items = <
				["at0000.1.1"] = <
					text = <"Palpation of the prostate">
					description = <"Findings observed by palpation of the prostate.">
				>
				["at0001.0.1"] = <
					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.">
				>
				["at0.0.1"] = <
					text = <"Prostate">
					description = <"The prostate was examined.">
				>
				["at0000"] = <
					text = <"Examination findings">
					description = <"Findings observed during the physical examination of a body system or anatomical structure.">
				>
				["at0000.1"] = <
					text = <"Palpation findings">
					description = <"Findings observed by palpation of an 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.">
				>
				["at0002"] = <
					text = <"No abnormality detected">
					description = <"Statement that no abnormality was detected (NAD) on physical examination.">
					comment = <"Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'.">
				>
				["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 = <"Coding of the 'Clinical interpretation' with a terminology is preferred, where possible.">
				>
				["at0007"] = <
					text = <"Comment">
					description = <"Additional narrative about the physical examination findings, not captured in other fields.">
				>
				["at0008"] = <
					text = <"Examination not done">
					description = <"Details to explicitly record that this examination was not performed.">
				>
				["at0011"] = <
					text = <"Structured body site">
					description = <"A structured description of the area of the body under examination.">
					comment = <"If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant.">
				>
				["at0012"] = <
					text = <"Body site">
					description = <"Identification of the area of the body under examination.">
					comment = <"If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant.">
				>
			>
		>
		["nb"] = <
			items = <
				["at0000.1.1"] = <
					text = <"*Palpation of the prostate (en)">
					description = <"Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur.">
				>
				["at0001.0.1"] = <
					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)">
				>
				["at0.0.1"] = <
					text = <"*Rectum (en)">
					description = <"*The rectum was examined. (en)">
				>
				["at0000.1"] = <
					text = <"*Palpation findings (en)">
					description = <"Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur.">
				>
				["at0000"] = <
					text = <"Undersøkelsesfunn">
					description = <"Funn ved fysisk undersøkelse av et organsystem eller anatomisk struktur.">
				>
				["at0001"] = <
					text = <"Undersøkt organsystem eller struktur">
					description = <"Identifisering av det undersøkte organsystemet eller anatomiske strukturen.">
					comment = <"*Coding of the system or structure examined with a terminology is preferred, where possible. (en)">
				>
				["at0002"] = <
					text = <"Uten anmerkning">
					description = <"Utsagn om at ingen avvik var oppdaget ved undersøkelsen (U.a.).">
					comment = <"*Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'. (en)">
				>
				["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 kliniske undersøkelsen.">
					comment = <"Koding med terminologi foretrekkes når mulig. For eksempel \"normal undersøkelse\" eller \"tympanisk membran perforasjon\".">
				>
				["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 anatomiske strukturen.">
					comment = <"Hvis anatomisk lokalisasjon er entydig identifisert i elementet \"Undersøkt organsystem eller struktur\" er dette SLOTet ikke nødvendig å benytte.">
				>
				["at0012"] = <
					text = <"Anatomisk lokalisasjon">
					description = <"Identifisering av et enkelt fysisk sted enten på eller i menneskekroppen.">
					comment = <"*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 = <
				["at0000"] = <[SNOMED-CT::5880005]>
				["at0000.1"] = <[SNOMED-CT::118242002]>
				["at0.0.1"] = <[SNOMED-CT::41216001]>
			>
		>
	>