Modellbiblioteket openEHR Fork
Name
Examination of a toe
Description
Findings observed during the physical examination of a toe.
Purpose
To record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe.
Use
Use to record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe.
This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the 'Procedure detail' SLOT within ACTION.procedure 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.
The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed.
Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the 'Procedure detail' SLOT within ACTION.procedure 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.
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.
Archetype Id
openEHR-EHR-CLUSTER.exam-toe.v0
Copyright
© openEHR Foundation
Licencing
This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
Original Author
Heather Leslie
Atomica Informatics
Atomica Informatics
Date Originally Authored
To record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe.
| 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
|
archetype (adl_version=1.4; uid=30b849ac-0676-492c-989e-2d3d4f9b77fd) openEHR-EHR-CLUSTER.exam-toe.v0 specialise openEHR-EHR-CLUSTER.exam.v2 concept [at0000.1] -- Examination of a toe 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"] = <"2021-03-31"> > details = < ["de"] = < language = <[ISO_639-1::de]> purpose = <"*To record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. (en)"> use = <"*Use to record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the 'Procedure detail' SLOT within ACTION.procedure 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. 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 = <"Nicht für die Dokumentation der Krankengeschichte zu verwenden - Für diesen Zweck sollten spezifische OBSERVATION- und CLUSTER-Archetypen verwendet werden, z.B. OBSERVATION.story und CLUSTER.symptom_sign."> copyright = <"© openEHR Foundation"> > ["sv"] = < language = <[ISO_639-1::sv]> purpose = <"*To record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. (en)"> use = <"*Use to record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the 'Procedure detail' SLOT within ACTION.procedure 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. 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 = <"Ska inte användas för att dokumentera anamnes eller historik, använd då istället specifika OBSERVATION- och CLUSTER-arketyper; exempelvis OBSERVATION.story och CLUSTER.symptom_sign."> copyright = <"© openEHR Foundation"> > ["nb"] = < language = <[ISO_639-1::nb]> purpose = <"*To record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. (en)"> use = <"*Use to record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the 'Procedure detail' SLOT within ACTION.procedure 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. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. (en)"> misuse = <"Skal ikke brukes til å ta opp 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 a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. (en)"> use = <"*Use to record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the 'Procedure detail' SLOT within ACTION.procedure 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. 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 = <"Não deve ser usado para registrar a história clínica - use arquétipos específicos de OBSERVAÇÃO e CLUSTER. Por exemplo, OBSERVATION.story e CLUSTER.symptom_sign."> copyright = <"© openEHR Foundation"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe."> use = <"Use to record a narrative description, structured details and clinical interpretation of the findings observed during the physical examination of a toe. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the OBSERVATION.exam or the 'Procedure detail' SLOT within ACTION.procedure 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. 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."> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"in_development"> other_contributors = <"Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)", "Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)", "SB Bhattacharyya, Sudisa Consultancy Services, India", "Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway", "Shahla Foozonkhah, Iran ministry of health and education, Iran", "Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)", "Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)", "Ingrid Heitmann, Oslo universitetssykehus HF, Norway", "Hilde Hollås, DIPS ASA, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Lars Ivar Mehlum, Helse Bergen HF, Norway", "Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Ian McNicoll, freshEHR Clinical Informatics, United Kingdom", "Lars Morgan Karlsen, DIPS ASA, Norway", "Bjørn Næss, DIPS ASA, Norway", "Andrej Orel, Marand d.o.o., Slovenia", "Vladimir Pizzo, Hospital Sírio Libanês, Brazil", "Jussara Rotzsch, UNB, Brazil", "Anoop Shah, University College London, United Kingdom", "Line Silsand, Universitetssykehuset i Nord-Norge, Norway", "Norwegian Review Summary, Nasjonal IKT HF, Norway", "Nyree Taylor, Ocean Informatics, Australia (openEHR Editor)", "Rowan Thomas, St. Vincent's Hospital Melbourne, Australia", "Jon Tysdahl, Furst medlab AS, Norway", "John Tore Valand, Helse Bergen, Norway (openEHR Editor)"> other_details = < ["licence"] = <"This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/."> ["custodian_organisation"] = <"openEHR Foundation"> ["current_contact"] = <"Heather Leslie, Atomica Informatics, Australia<heather.leslie@atomicainformatics.com>"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"038073C4585E34F60245D317B59C3FE4"> ["build_uid"] = <"3c966a45-34c2-421b-91c3-cae58ff78231"> ["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 a toe 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 great toe at0.2, -- Left second toe at0.3, -- Left third toe at0.4, -- Left fourth toe at0.5, -- Left fifth toe at0.6, -- Right great toe at0.7, -- Right second toe at0.8, -- Right third toe at0.9, -- Right fourth toe at0.10] -- Right fifth toe } } } } 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-toenail(-[a-zA-Z0-9_]+)*\.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/} } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["en"] = < items = < ["at0000.1"] = < text = <"Examination of a toe"> description = <"Findings observed during the physical examination of a toe."> > ["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 great toe"> description = <"The great toe of the left foot."> > ["at0.2"] = < text = <"Left second toe"> description = <"The second toe of the left foot."> > ["at0.3"] = < text = <"Left third toe"> description = <"The third toe of the left foot."> > ["at0.4"] = < text = <"Left fourth toe"> description = <"The fourth toe of the left foot."> > ["at0.5"] = < text = <"Left fifth toe"> description = <"The fifth toe of the left foot."> > ["at0.6"] = < text = <"Right great toe"> description = <"The great toe of the right foot."> > ["at0.7"] = < text = <"Right second toe"> description = <"The second toe of the right foot."> > ["at0.8"] = < text = <"Right third toe"> description = <"The third toe of the right foot."> > ["at0.9"] = < text = <"Right fourth toe"> description = <"The fourth toe of the right foot."> > ["at0.10"] = < text = <"Right fifth toe"> description = <"The fifth toe of the right foot."> > ["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."> > ["at0006"] = < text = <"Clinical interpretation"> description = <"Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings."> comment = <"For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible."> > ["at0007"] = < text = <"Comment"> description = <"Additional narrative about the physical examination findings, not captured in other fields."> > ["at0008"] = < text = <"Examination not done"> description = <"Details to explicitly record that this examination was not performed."> > ["at0011"] = < text = <"Structured body site"> description = <"A structured description of the area of the body under examination."> comment = <"If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant."> > ["at0012"] = < text = <"Body site"> description = <"Identification of the area of the body under examination."> comment = <"If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant."> > > > ["nb"] = < items = < ["at0000.1"] = < text = <"*Examination of a toe (en)"> description = <"*Findings observed during the physical examination of a toe. (en)"> > ["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 great toe (en)"> description = <"*The great toe of the left foot. (en)"> > ["at0.2"] = < text = <"*Left second toe (en)"> description = <"*The second toe of the left foot. (en)"> > ["at0.3"] = < text = <"*Left third toe (en)"> description = <"*The third toe of the left foot. (en)"> > ["at0.4"] = < text = <"*Left fourth toe (en)"> description = <"*The fourth toe of the left foot. (en)"> > ["at0.5"] = < text = <"*Left fifth toe (en)"> description = <"*The fifth toe of the left foot. (en)"> > ["at0.6"] = < text = <"*Right great toe (en)"> description = <"*The great toe of the right foot. (en)"> > ["at0.7"] = < text = <"*Right second toe (en)"> description = <"*The second toe of the right foot. (en)"> > ["at0.8"] = < text = <"*Right third toe (en)"> description = <"*The third toe of the right foot. (en)"> > ["at0.9"] = < text = <"*Right fourth toe (en)"> description = <"*The fourth toe of the right foot. (en)"> > ["at0.10"] = < text = <"*Right fifth toe (en)"> description = <"*The fifth toe of the right foot. (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."> > ["at0001"] = < text = <"Undersøkt organsystem eller struktur"> description = <"Identifisering av det undersøkte organsystemet eller den anatomiske strukturen."> comment = <"Det anbefales å kode organsystem eller den anatomiske strukturen med en terminologi dersom mulig."> > ["at0003"] = < text = <"Klinisk beskrivelse"> description = <"Fritekstbeskrivelse av de overordnede funnene ved den fysiske undersøkelsen."> > ["at0004"] = < text = <"Spesifikke funn"> description = <"Ytterligere strukturerte detaljer om undersøkelsesfunnene."> > ["at0005"] = < text = <"Multimediarepresentasjon"> description = <"Digitale bilder, video eller diagram som representerer undersøkelsesfunnene."> > ["at0006"] = < text = <"Fortolkning"> description = <"Enkelt ord, setning, frase eller kort beskrivelse som representerer den kliniske betydning og viktigheten av funnene ved den fysiske undersøkelsen."> comment = <"For eksempel \"Uten anmerkning\" eller \"Moderat inflammasjon\". Det anbefales å kode \"Fortolkning\" med en terminologi dersom mulig."> > ["at0007"] = < text = <"Kommentar"> description = <"Ytterligere fritekst om funn ved undersøkelsen, som ikke dekkes av andre elementer."> > ["at0008"] = < text = <"Undersøkelse ikke utført"> description = <"Detaljer for å eksplisitt registrere at denne undersøkelsen ikke ble utført."> > ["at0011"] = < text = <"Strukturert anatomisk lokalisasjon"> description = <"Angivelse av en strukturert anatomisk lokalisering av det undersøkte organsystemet eller den anatomiske strukturen."> comment = <"Hvis anatomisk lokalisasjon er entydig identifisert i elementet \"Undersøkt organsystem eller struktur\" er dette SLOT'et ikke nødvendig å benytte."> > ["at0012"] = < text = <"Anatomisk lokalisasjon"> description = <"Identifisering av et enkelt fysisk sted enten på eller i menneskekroppen."> comment = <"Dersom den anatomiske lokaliseringen allerede er identifisert i elementet \"Undersøkt organsystem eller struktur\" er dette dataelementet overflødig."> > > > ["pt-br"] = < items = < ["at0000.1"] = < text = <"*Examination of a toe (en)"> description = <"*Findings observed during the physical examination of a toe. (en)"> > ["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 great toe (en)"> description = <"*The great toe of the left foot. (en)"> > ["at0.2"] = < text = <"*Left second toe (en)"> description = <"*The second toe of the left foot. (en)"> > ["at0.3"] = < text = <"*Left third toe (en)"> description = <"*The third toe of the left foot. (en)"> > ["at0.4"] = < text = <"*Left fourth toe (en)"> description = <"*The fourth toe of the left foot. (en)"> > ["at0.5"] = < text = <"*Left fifth toe (en)"> description = <"*The fifth toe of the left foot. (en)"> > ["at0.6"] = < text = <"*Right great toe (en)"> description = <"*The great toe of the right foot. (en)"> > ["at0.7"] = < text = <"*Right second toe (en)"> description = <"*The second toe of the right foot. (en)"> > ["at0.8"] = < text = <"*Right third toe (en)"> description = <"*The third toe of the right foot. (en)"> > ["at0.9"] = < text = <"*Right fourth toe (en)"> description = <"*The fourth toe of the right foot. (en)"> > ["at0.10"] = < text = <"*Right fifth toe (en)"> description = <"*The fifth toe of the right foot. (en)"> > ["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."> > ["at0006"] = < text = <"Interpretação clínica"> description = <"Palavra, frase ou breve descrição que represente o significado clínico e o significado dos resultados do exame físico."> comment = <"*For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. (en)"> > ["at0007"] = < text = <"Comentário"> description = <"Narrativa adicional sobre os achados do exame físico, não capturados em outros campos."> > ["at0008"] = < text = <"Exame não realizado"> description = <"Detalhes para registrar explicitamente que esse exame não foi realizado."> > ["at0011"] = < text = <"Local do corpo estruturado"> description = <"Uma descrição estruturada da área do corpo em exame."> comment = <"Se o local do corpo tiver sido totalmente identificado no elemento de dados 'Sistema ou estrutura examinada' ou 'Local do corpo', esse SLOT se tornará redundante."> > ["at0012"] = < text = <"Local do corpo"> description = <"Identificação da área do corpo em exame."> comment = <"Se o local do corpo foi totalmente identificado no elemento de dados 'Sistema ou estrutura examinada', esse elemento de dados se torna redundante."> > > > ["de"] = < items = < ["at0000.1"] = < text = <"*Examination of a toe (en)"> description = <"*Findings observed during the physical examination of a toe. (en)"> > ["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 great toe (en)"> description = <"*The great toe of the left foot. (en)"> > ["at0.2"] = < text = <"*Left second toe (en)"> description = <"*The second toe of the left foot. (en)"> > ["at0.3"] = < text = <"*Left third toe (en)"> description = <"*The third toe of the left foot. (en)"> > ["at0.4"] = < text = <"*Left fourth toe (en)"> description = <"*The fourth toe of the left foot. (en)"> > ["at0.5"] = < text = <"*Left fifth toe (en)"> description = <"*The fifth toe of the left foot. (en)"> > ["at0.6"] = < text = <"*Right great toe (en)"> description = <"*The great toe of the right foot. (en)"> > ["at0.7"] = < text = <"*Right second toe (en)"> description = <"*The second toe of the right foot. (en)"> > ["at0.8"] = < text = <"*Right third toe (en)"> description = <"*The third toe of the right foot. (en)"> > ["at0.9"] = < text = <"*Right fourth toe (en)"> description = <"*The fourth toe of the right foot. (en)"> > ["at0.10"] = < text = <"*Right fifth toe (en)"> description = <"*The fifth toe of the right foot. (en)"> > ["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."> > ["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)"> > ["at0007"] = < text = <"Kommentar"> description = <"Zusätzliche Beschreibung der Ergebnisse der körperlichen Untersuchung, die in anderen Bereichen nicht erfasst werden konnten."> > ["at0008"] = < text = <"Nicht durchgeführte Untersuchung"> description = <"Eine Aussage die ausdrücklich erfasst, dass die Untersuchung nicht durchgeführt wurde."> > ["at0011"] = < text = <"Strukturierte Körperstelle"> description = <"Eine strukturierte Beschreibung des zu untersuchenden Körperbereichs."> comment = <"Wenn die Körperstelle im Datenelement \"Untersuchtes System oder untersuchte Struktur\" oder im Datenelement \"Körperstelle\" vollständig identifiziert wurde, wird die Verwendung dieses SLOT überflüssig."> > ["at0012"] = < text = <"Körperstelle"> description = <"Identifizierung des Untersuchungsbereichs."> comment = <"Wenn die Körperstelle im Datenelement \"Untersuchtes System oder untersuchte Struktur\" vollständig identifiziert wurde, wird dieses Datenelement überflüssig."> > > > ["sv"] = < items = < ["at0000.1"] = < text = <"*Examination of a toe (en)"> description = <"*Findings observed during the physical examination of a toe. (en)"> > ["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 great toe (en)"> description = <"*The great toe of the left foot. (en)"> > ["at0.2"] = < text = <"*Left second toe (en)"> description = <"*The second toe of the left foot. (en)"> > ["at0.3"] = < text = <"*Left third toe (en)"> description = <"*The third toe of the left foot. (en)"> > ["at0.4"] = < text = <"*Left fourth toe (en)"> description = <"*The fourth toe of the left foot. (en)"> > ["at0.5"] = < text = <"*Left fifth toe (en)"> description = <"*The fifth toe of the left foot. (en)"> > ["at0.6"] = < text = <"*Right great toe (en)"> description = <"*The great toe of the right foot. (en)"> > ["at0.7"] = < text = <"*Right second toe (en)"> description = <"*The second toe of the right foot. (en)"> > ["at0.8"] = < text = <"*Right third toe (en)"> description = <"*The third toe of the right foot. (en)"> > ["at0.9"] = < text = <"*Right fourth toe (en)"> description = <"*The fourth toe of the right foot. (en)"> > ["at0.10"] = < text = <"*Right fifth toe (en)"> description = <"*The fifth toe of the right foot. (en)"> > ["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."> > ["at0006"] = < text = <"Klinisk tolkning"> description = <"Ord, fras eller kort beskrivning av fyndens kliniska betydelse."> comment = <"*For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. (en)"> > ["at0007"] = < text = <"Kommentar"> description = <"Kommentarer avseende undersökningsfynd som inte beskrivs i övriga fält."> > ["at0008"] = < text = <"Undersökning ej genomförd"> description = <"Detaljerad beskrivning om att undersökningen inte genomfördes."> > ["at0011"] = < text = <"Strukturerad anatomisk plats"> description = <"Strukturerad beskrivning av den anatomiska platsen som undersökts."> comment = <"Om den anatomiska platsen kan identifieras helt via dataelementet \"System eller struktur som undersökts\" så blir denna del redundant."> > ["at0012"] = < text = <"Anatomisk plats"> description = <"Identifiering av den anatomiska plats som undersökts. "> comment = <"Om den anatomiska platsen har identifierats fullt ut i \"System eller struktur som undersökts\" så blir detta element redundant. "> > > > > term_bindings = < ["SNOMED-CT"] = < items = < ["at0000.1"] = <[SNOMED-CT::284385006]> ["at0000"] = <[SNOMED-CT::5880005]> > > >