Modellbiblioteket openEHR Fork
Name
Examination of a tooth
Description
Findings observed during the physical examination of a single tooth.
Purpose
To record a narrative description and clinical interpretation of the findings observed during the physical examination of a single tooth.
Use
Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of a single tooth.
This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the 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.
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 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.
References
Periobasics.com [Internet]. Dr Nitin Saroch. The art of history taking in periodontology [cited 2019 May 16]. Available from: https://periobasics.com/the-art-of-taking-case-history.html.
Archetype Id
openEHR-EHR-CLUSTER.exam-tooth.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 and clinical interpretation of the findings observed during the physical examination of a single tooth.
| 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
|
|
Tooth position
|
0..1 | DV_TEXT |
Identification of the position of the identified tooth.
|
|
Structured tooth position
|
0..* | Slot (Cluster) |
A structured description of the position of the identified tooth.
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
|
|
Tooth label
|
0..1 | DV_TEXT |
Name or nomenclature of the tooth examined.
Comment
For example: upper right permanent canine can be represented by the label '13' using ISO system; '3' using the Palmer notation; or '6' using the Universal numbering system.
|
|
Presence
|
0..1 | DV_CODED_TEXT |
Presence or absence of the identified tooth.
Constraint for DV_CODED_TEXT
|
|
Condition
|
0..1 | DV_CODED_TEXT |
Has the tooth been restored?
Constraint for DV_CODED_TEXT
|
|
Gum description
|
0..1 | DV_TEXT |
Narrative description about the gum of the identified tooth.
|
|
Pocket depth
|
0..1 | DV_QUANTITY |
The depth of the gum pocket.
DV_QUANTITY
|
Findings
|
0..* | CLUSTER |
Details about the findings observed.
CLUSTER
|
|
Finding
|
0..1 |
CHOICE OF
DV_CODED_TEXT
DV_TEXT
|
Constraint for DV_CODED_TEXT
|
|
Surface
|
0..1 | DV_CODED_TEXT |
Surface of the tooth where the finding is observed.
Constraint for DV_CODED_TEXT
|
|
Clinical description
|
0..1 | DV_TEXT |
Narrative description about the finding.
|
archetype (adl_version=1.4; uid=0ccafa67-ad91-4e89-aa5b-443cf0442bd9) openEHR-EHR-CLUSTER.exam-tooth.v0 specialise openEHR-EHR-CLUSTER.exam.v2 concept [at0000.1] -- Examination of a tooth 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"] = <"2019-05-16"> > 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."> > ["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 a single tooth."> use = <"Use to record a narrative description and clinical interpretation of the findings observed during the physical examination of a single tooth. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the 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. 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"> ["references"] = <"Periobasics.com [Internet]. Dr Nitin Saroch. The art of history taking in periodontology [cited 2019 May 16]. Available from: https://periobasics.com/the-art-of-taking-case-history.html."> ["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"] = <"C8E5958F7ABF215D8946E14DF5B38A5A"> ["build_uid"] = <"abe2efa2-dc13-44be-9594-bba2a3a15d55"> ["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 tooth 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] -- Tooth } } } } ELEMENT[at0012.1] occurrences matches {0..1} matches { -- Tooth position value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0011.1] occurrences matches {0..*} matches { -- Structured tooth position 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\.v2/} } ELEMENT[at0003] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0004] occurrences matches {0..*} matches { -- Examination findings include archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches { -- Multimedia representation include archetype_id/value matches {/openEHR-EHR-CLUSTER\.media_file(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0006] occurrences matches {0..*} matches { -- Clinical interpretation value matches { DV_TEXT matches {*} } } ELEMENT[at0007] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0008] occurrences matches {0..*} matches { -- Examination not done include archetype_id/value matches {/openEHR-EHR-CLUSTER\.exclusion_exam(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0.2] occurrences matches {0..1} matches { -- Tooth label value matches { DV_TEXT matches {*} } } ELEMENT[at0.3] occurrences matches {0..1} matches { -- Presence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.4, -- Present at0.5] -- Absent } } } } ELEMENT[at0.6] occurrences matches {0..1} matches { -- Condition value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.7, -- Unrestored at0.8] -- Restored. } } } } ELEMENT[at0.9] occurrences matches {0..1} matches { -- Gum description value matches { DV_TEXT matches {*} } } ELEMENT[at0.10] occurrences matches {0..1} matches { -- Pocket depth value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"mm"> magnitude = <|0.0..10.0|> precision = <|0|> > > > } } CLUSTER[at0.11] occurrences matches {0..*} matches { -- Findings items cardinality matches {1..*; unordered} matches { ELEMENT[at0.12] occurrences matches {0..1} matches { -- Finding value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.13, -- Cavity at0.14, -- Amalgam at0.15, -- Gold inlay at0.16, -- Gold foil at0.17, -- Other metal restoration at0.18, -- Composite resin at0.19, -- Traumatic avulsion at0.20, -- Fractured crown at0.21, -- Root tip at0.22, -- Rotated at0.23, -- Root apical filling at0.24, -- Apicoectomy at0.25, -- Intermediate restoration at0.26, -- Crown - temporary at0.27, -- Crown - full at0.28, -- Crown - partial at0.29] -- Crown veneer } } DV_TEXT matches {*} } } ELEMENT[at0.30] occurrences matches {0..1} matches { -- Surface value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.31, -- Mesial at0.32, -- Distal at0.33, -- Buccal at0.34, -- Lingual at0.35, -- Incisal at0.36] -- Occlusal } } } } ELEMENT[at0.37] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } } } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["en"] = < items = < ["at0000.1"] = < text = <"Examination of a tooth"> description = <"Findings observed during the physical examination of a single tooth."> > ["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 = <"Tooth"> description = <"A hard, bony enamel-coated structure in the jaw used, for biting and chewing."> > ["at0.2"] = < text = <"Tooth label"> description = <"Name or nomenclature of the tooth examined."> comment = <"For example: upper right permanent canine can be represented by the label '13' using ISO system; '3' using the Palmer notation; or '6' using the Universal numbering system."> > ["at0.3"] = < text = <"Presence"> description = <"Presence or absence of the identified tooth."> > ["at0.4"] = < text = <"Present"> description = <"The identified tooth is present."> > ["at0.5"] = < text = <"Absent"> description = <"The identified tooth is absent."> > ["at0012.1"] = < text = <"Tooth position"> description = <"Identification of the position of the identified tooth."> > ["at0011.1"] = < text = <"Structured tooth position"> description = <"A structured description of the position of the identified tooth."> > ["at0.6"] = < text = <"Condition"> description = <"Has the tooth been restored?"> > ["at0.7"] = < text = <"Unrestored"> description = <"The tooth has no repairs or restorations observed."> > ["at0.8"] = < text = <"Restored."> description = <"The tooth has repairs or restorations."> > ["at0.9"] = < text = <"Gum description"> description = <"Narrative description about the gum of the identified tooth."> > ["at0.10"] = < text = <"Pocket depth"> description = <"The depth of the gum pocket."> > ["at0000"] = < text = <"Examination findings"> description = <"Findings observed during the physical examination of a body system or anatomical structure."> > ["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'."> > ["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."> > ["at0.11"] = < text = <"Findings"> description = <"Details about the findings observed."> > ["at0.12"] = < text = <"Finding"> description = <""> > ["at0.13"] = < text = <"Cavity"> description = <""> > ["at0.14"] = < text = <"Amalgam"> description = <""> > ["at0.15"] = < text = <"Gold inlay"> description = <""> > ["at0.16"] = < text = <"Gold foil"> description = <""> > ["at0.17"] = < text = <"Other metal restoration"> description = <""> > ["at0.18"] = < text = <"Composite resin"> description = <""> > ["at0.19"] = < text = <"Traumatic avulsion"> description = <""> > ["at0.20"] = < text = <"Fractured crown"> description = <""> > ["at0.21"] = < text = <"Root tip"> description = <""> > ["at0.22"] = < text = <"Rotated"> description = <""> > ["at0.23"] = < text = <"Root apical filling"> description = <""> > ["at0.24"] = < text = <"Apicoectomy"> description = <""> > ["at0.25"] = < text = <"Intermediate restoration"> description = <""> > ["at0.26"] = < text = <"Crown - temporary"> description = <""> > ["at0.27"] = < text = <"Crown - full"> description = <""> > ["at0.28"] = < text = <"Crown - partial"> description = <""> > ["at0.29"] = < text = <"Crown veneer"> description = <""> > ["at0.30"] = < text = <"Surface"> description = <"Surface of the tooth where the finding is observed."> > ["at0.31"] = < text = <"Mesial"> description = <"The surface that is closest to the midline of the face."> > ["at0.32"] = < text = <"Distal"> description = <"The surface that is furthest from the midline of the face."> > ["at0.33"] = < text = <"Buccal"> description = <"The surface that faces towards the cheeks."> > ["at0.34"] = < text = <"Lingual"> description = <"The surface that faces towards the tongue."> > ["at0.35"] = < text = <"Incisal"> description = <"The biting edge of an anterior tooth."> > ["at0.36"] = < text = <"Occlusal"> description = <"The chewing surface of a posterior tooth."> > ["at0.37"] = < text = <"Clinical description"> description = <"Narrative description about the finding."> > ["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 = < ["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."> > ["at0000.1"] = < text = <"*Examination of a tooth (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 = <"*Tooth (en)"> description = <"*A hard, bony enamel-coated structure in the jaw used, for biting and chewing. (en)"> > ["at0.2"] = < text = <"*Tooth label (en)"> description = <"*Name or nomenclature of the tooth examined. (en)"> comment = <"*For example: upper right permanent canine can be represented by the label '13' using ISO system; '3' using the Palmer notation; or '6' using the Universal numbering system. (en)"> > ["at0.3"] = < text = <"*Presence (en)"> description = <"*Presence or absence of the identified tooth. (en)"> > ["at0.4"] = < text = <"*Present (en)"> description = <"*The identified tooth is present. (en)"> > ["at0.5"] = < text = <"*Absent (en)"> description = <"*The identified tooth is absent. (en)"> > ["at0012.1"] = < text = <"*Tooth position (en)"> description = <"*Identification of the position of the identified tooth. (en)"> > ["at0011.1"] = < text = <"*Structured tooth position (en)"> description = <"*A structured description of the position of the identified tooth. (en)"> > ["at0.6"] = < text = <"*Condition (en)"> description = <"*Has the tooth been restored? (en)"> > ["at0.7"] = < text = <"*Unrestored (en)"> description = <"*The tooth has no repairs or restorations observed. (en)"> > ["at0.8"] = < text = <"*Restored. (en)"> description = <"*The tooth has repairs or restorations. (en)"> > ["at0.9"] = < text = <"*Gum description (en)"> description = <"*Narrative description about the gum of the identified tooth. (en)"> > ["at0.10"] = < text = <"*Pocket depth (en)"> description = <"*The depth of the gum pocket. (en)"> > ["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."> > ["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)"> > ["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."> > ["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."> > ["at0.11"] = < text = <"*Findings (en)"> description = <"*Details about the findings observed. (en)"> > ["at0.12"] = < text = <"*Finding (en)"> description = <""> > ["at0.13"] = < text = <"*Cavity (en)"> description = <""> > ["at0.14"] = < text = <"*Amalgam (en)"> description = <""> > ["at0.15"] = < text = <"*Gold inlay (en)"> description = <""> > ["at0.16"] = < text = <"*Gold foil (en)"> description = <""> > ["at0.17"] = < text = <"*Other metal restoration (en)"> description = <""> > ["at0.18"] = < text = <"*Composite resin (en)"> description = <""> > ["at0.19"] = < text = <"*Traumatic avulsion (en)"> description = <""> > ["at0.20"] = < text = <"*Fractured crown (en)"> description = <""> > ["at0.21"] = < text = <"*Root tip (en)"> description = <""> > ["at0.22"] = < text = <"*Rotated (en)"> description = <""> > ["at0.23"] = < text = <"*Root apical filling (en)"> description = <""> > ["at0.24"] = < text = <"*Apicoectomy (en)"> description = <""> > ["at0.25"] = < text = <"*Intermediate restoration (en)"> description = <""> > ["at0.26"] = < text = <"*Crown - temporary (en)"> description = <""> > ["at0.27"] = < text = <"*Crown - full (en)"> description = <""> > ["at0.28"] = < text = <"*Crown - partial (en)"> description = <""> > ["at0.29"] = < text = <"*Crown veneer (en)"> description = <""> > ["at0.30"] = < text = <"*Surface (en)"> description = <"*Surface of the tooth where the finding is observed. (en)"> > ["at0.31"] = < text = <"*Mesial (en)"> description = <"*The surface that is closest to the midline of the face. (en)"> > ["at0.32"] = < text = <"*Distal (en)"> description = <"*The surface that is furthest from the midline of the face. (en)"> > ["at0.33"] = < text = <"*Buccal (en)"> description = <"*The surface that faces towards the cheeks. (en)"> > ["at0.34"] = < text = <"*Lingual (en)"> description = <"*The surface that faces towards the tongue. (en)"> > ["at0.35"] = < text = <"*Incisal (en)"> description = <"*The biting edge of an anterior tooth. (en)"> > ["at0.36"] = < text = <"*Occlusal (en)"> description = <"*The chewing surface of a posterior tooth. (en)"> > ["at0.37"] = < text = <"*Clinical description (en)"> description = <"*Narrative description about the finding. (en)"> > ["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 = < ["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 = <"Tooth"> description = <"A hard, bony enamel-coated structure in the jaw used, for biting and chewing."> > ["at0.2"] = < text = <"Tooth label"> description = <"Name or nomenclature of the tooth examined."> comment = <"For example: upper right permanent canine can be represented by the label '13' using ISO system; '3' using the Palmer notation; or '6' using the Universal numbering system."> > ["at0.3"] = < text = <"Presence"> description = <"Presence or absence of the identified tooth."> > ["at0.4"] = < text = <"Present"> description = <"The identified tooth is present."> > ["at0.5"] = < text = <"Absent"> description = <"The identified tooth is absent."> > ["at0012.1"] = < 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."> > ["at0011.1"] = < 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."> > ["at0.6"] = < text = <"Condition"> description = <"Has the tooth been restored?"> > ["at0.7"] = < text = <"Unrestored"> description = <"The tooth has no repairs or restorations observed."> > ["at0.8"] = < text = <"Restored."> description = <"The tooth has repairs or restorations."> > ["at0.9"] = < text = <"Gum description"> description = <"Narrative description about the gum of the identified tooth."> > ["at0.10"] = < text = <"Pocket depth"> description = <"The depth of the gum pocket."> > ["at0000"] = < text = <"Resultados do exame"> description = <"Constatações observadas durante o exame físico de um sistema corporal ou estrutura anatômica."> > ["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'."> > ["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)"> > ["at0.11"] = < text = <"Findings"> description = <"Details about the findings observed."> > ["at0.12"] = < text = <"Finding"> description = <""> > ["at0.13"] = < text = <"Cavity"> description = <""> > ["at0.14"] = < text = <"Amalgam"> description = <""> > ["at0.15"] = < text = <"Gold inlay"> description = <""> > ["at0.16"] = < text = <"Gold foil"> description = <""> > ["at0.17"] = < text = <"Other metal restoration"> description = <""> > ["at0.18"] = < text = <"Composite resin"> description = <""> > ["at0.19"] = < text = <"Traumatic avulsion"> description = <""> > ["at0.20"] = < text = <"Fractured crown"> description = <""> > ["at0.21"] = < text = <"Root tip"> description = <""> > ["at0.22"] = < text = <"Rotated"> description = <""> > ["at0.23"] = < text = <"Root apical filling"> description = <""> > ["at0.24"] = < text = <"Apicoectomy"> description = <""> > ["at0.25"] = < text = <"Intermediate restoration"> description = <""> > ["at0.26"] = < text = <"Crown - temporary"> description = <""> > ["at0.27"] = < text = <"Crown - full"> description = <""> > ["at0.28"] = < text = <"Crown - partial"> description = <""> > ["at0.29"] = < text = <"Crown veneer"> description = <""> > ["at0.30"] = < text = <"Surface"> description = <"Surface of the tooth where the finding is observed."> > ["at0.31"] = < text = <"Mesial"> description = <"The surface that is closest to the midline of the face."> > ["at0.32"] = < text = <"Distal"> description = <"The surface that is furthest from the midline of the face."> > ["at0.33"] = < text = <"Buccal"> description = <"The surface that faces towards the cheeks."> > ["at0.34"] = < text = <"Lingual"> description = <"The surface that faces towards the tongue."> > ["at0.35"] = < text = <"Incisal"> description = <"The biting edge of an anterior tooth."> > ["at0.36"] = < text = <"Occlusal"> description = <"The chewing surface of a posterior tooth."> > ["at0.37"] = < text = <"Clinical description"> description = <"Narrative description about the finding."> > ["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 = < ["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 = <"Tooth"> description = <"A hard, bony enamel-coated structure in the jaw used, for biting and chewing."> > ["at0.2"] = < text = <"Tooth label"> description = <"Name or nomenclature of the tooth examined."> comment = <"For example: upper right permanent canine can be represented by the label '13' using ISO system; '3' using the Palmer notation; or '6' using the Universal numbering system."> > ["at0.3"] = < text = <"Presence"> description = <"Presence or absence of the identified tooth."> > ["at0.4"] = < text = <"Present"> description = <"The identified tooth is present."> > ["at0.5"] = < text = <"Absent"> description = <"The identified tooth is absent."> > ["at0012.1"] = < text = <"Körperstelle"> description = <"Identifizierung des Untersuchungsbereichs."> comment = <"Wenn die Körperstelle im Datenelement \"Untersuchtes System oder untersuchte Struktur\" vollständig identifiziert wurde, wird dieses Datenelement überflüssig."> > ["at0011.1"] = < 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."> > ["at0.6"] = < text = <"Condition"> description = <"Has the tooth been restored?"> > ["at0.7"] = < text = <"Unrestored"> description = <"The tooth has no repairs or restorations observed."> > ["at0.8"] = < text = <"Restored."> description = <"The tooth has repairs or restorations."> > ["at0.9"] = < text = <"Gum description"> description = <"Narrative description about the gum of the identified tooth."> > ["at0.10"] = < text = <"Pocket depth"> description = <"The depth of the gum pocket."> > ["at0000"] = < text = <"Untersuchungsergebnisse"> description = <"Während der körperlichen Untersuchung eines Körpersystems oder einer anatomischen Struktur beobachtete Befunde."> > ["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'."> > ["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)"> > ["at0.11"] = < text = <"Findings"> description = <"Details about the findings observed."> > ["at0.12"] = < text = <"Finding"> description = <""> > ["at0.13"] = < text = <"Cavity"> description = <""> > ["at0.14"] = < text = <"Amalgam"> description = <""> > ["at0.15"] = < text = <"Gold inlay"> description = <""> > ["at0.16"] = < text = <"Gold foil"> description = <""> > ["at0.17"] = < text = <"Other metal restoration"> description = <""> > ["at0.18"] = < text = <"Composite resin"> description = <""> > ["at0.19"] = < text = <"Traumatic avulsion"> description = <""> > ["at0.20"] = < text = <"Fractured crown"> description = <""> > ["at0.21"] = < text = <"Root tip"> description = <""> > ["at0.22"] = < text = <"Rotated"> description = <""> > ["at0.23"] = < text = <"Root apical filling"> description = <""> > ["at0.24"] = < text = <"Apicoectomy"> description = <""> > ["at0.25"] = < text = <"Intermediate restoration"> description = <""> > ["at0.26"] = < text = <"Crown - temporary"> description = <""> > ["at0.27"] = < text = <"Crown - full"> description = <""> > ["at0.28"] = < text = <"Crown - partial"> description = <""> > ["at0.29"] = < text = <"Crown veneer"> description = <""> > ["at0.30"] = < text = <"Surface"> description = <"Surface of the tooth where the finding is observed."> > ["at0.31"] = < text = <"Mesial"> description = <"The surface that is closest to the midline of the face."> > ["at0.32"] = < text = <"Distal"> description = <"The surface that is furthest from the midline of the face."> > ["at0.33"] = < text = <"Buccal"> description = <"The surface that faces towards the cheeks."> > ["at0.34"] = < text = <"Lingual"> description = <"The surface that faces towards the tongue."> > ["at0.35"] = < text = <"Incisal"> description = <"The biting edge of an anterior tooth."> > ["at0.36"] = < text = <"Occlusal"> description = <"The chewing surface of a posterior tooth."> > ["at0.37"] = < text = <"Clinical description"> description = <"Narrative description about the finding."> > ["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 = < ["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 = <"Tooth"> description = <"A hard, bony enamel-coated structure in the jaw used, for biting and chewing."> > ["at0.2"] = < text = <"Tooth label"> description = <"Name or nomenclature of the tooth examined."> comment = <"For example: upper right permanent canine can be represented by the label '13' using ISO system; '3' using the Palmer notation; or '6' using the Universal numbering system."> > ["at0.3"] = < text = <"Presence"> description = <"Presence or absence of the identified tooth."> > ["at0.4"] = < text = <"Present"> description = <"The identified tooth is present."> > ["at0.5"] = < text = <"Absent"> description = <"The identified tooth is absent."> > ["at0012.1"] = < 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. "> > ["at0011.1"] = < 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."> > ["at0.6"] = < text = <"Condition"> description = <"Has the tooth been restored?"> > ["at0.7"] = < text = <"Unrestored"> description = <"The tooth has no repairs or restorations observed."> > ["at0.8"] = < text = <"Restored."> description = <"The tooth has repairs or restorations."> > ["at0.9"] = < text = <"Gum description"> description = <"Narrative description about the gum of the identified tooth."> > ["at0.10"] = < text = <"Pocket depth"> description = <"The depth of the gum pocket."> > ["at0000"] = < text = <"Fynd vid undersökning"> description = <"Observerade fynd vid fysisk undersökning av system i kroppen, eller av anatomisk struktur"> > ["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'."> > ["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)"> > ["at0.11"] = < text = <"Findings"> description = <"Details about the findings observed."> > ["at0.12"] = < text = <"Finding"> description = <""> > ["at0.13"] = < text = <"Cavity"> description = <""> > ["at0.14"] = < text = <"Amalgam"> description = <""> > ["at0.15"] = < text = <"Gold inlay"> description = <""> > ["at0.16"] = < text = <"Gold foil"> description = <""> > ["at0.17"] = < text = <"Other metal restoration"> description = <""> > ["at0.18"] = < text = <"Composite resin"> description = <""> > ["at0.19"] = < text = <"Traumatic avulsion"> description = <""> > ["at0.20"] = < text = <"Fractured crown"> description = <""> > ["at0.21"] = < text = <"Root tip"> description = <""> > ["at0.22"] = < text = <"Rotated"> description = <""> > ["at0.23"] = < text = <"Root apical filling"> description = <""> > ["at0.24"] = < text = <"Apicoectomy"> description = <""> > ["at0.25"] = < text = <"Intermediate restoration"> description = <""> > ["at0.26"] = < text = <"Crown - temporary"> description = <""> > ["at0.27"] = < text = <"Crown - full"> description = <""> > ["at0.28"] = < text = <"Crown - partial"> description = <""> > ["at0.29"] = < text = <"Crown veneer"> description = <""> > ["at0.30"] = < text = <"Surface"> description = <"Surface of the tooth where the finding is observed."> > ["at0.31"] = < text = <"Mesial"> description = <"The surface that is closest to the midline of the face."> > ["at0.32"] = < text = <"Distal"> description = <"The surface that is furthest from the midline of the face."> > ["at0.33"] = < text = <"Buccal"> description = <"The surface that faces towards the cheeks."> > ["at0.34"] = < text = <"Lingual"> description = <"The surface that faces towards the tongue."> > ["at0.35"] = < text = <"Incisal"> description = <"The biting edge of an anterior tooth."> > ["at0.36"] = < text = <"Occlusal"> description = <"The chewing surface of a posterior tooth."> > ["at0.37"] = < text = <"Clinical description"> description = <"Narrative description about the finding."> > ["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::38199008]> ["at0000"] = <[SNOMED-CT::5880005]> > > >