Our current Examination findings (CLUSTER.exam) pattern was established in 2015, based on five years of trial and error, and published in 2017. It’s proven to work very well for both generic use and specialisation to enable representation of the examination of all kinds of assumed normal body structures, as well as query using terminologies.
However, its use of a “No abnormality detected” boolean element makes it unusable for representing the examination of structures which are assumed abnormal, such as surface lesions of all types, fractures, masses, etc.
Therefore we’re proposing a major change where we remove the “No abnormality detected” element, using the “Clinical interpretation” element to represent this information where relevant.
We’re planning to send the archetype out for a new review round, and would welcome any input in the reviews. Please adopt the archetype to make sure you’ll be invited to the review! 