# General examination archetype **Category:** [Clinical (archive)](https://discourse.openehr.org/c/clinical-archive/153) **Created:** 2008-10-23 22:06 UTC **Views:** 4 **Replies:** 2 **URL:** https://discourse.openehr.org/t/general-examination-archetype/12583 --- ## Post #1 by @Greg_Caulton I have an Archetype question on openEHR\-EHR\-CLUSTER\.exam\.v1 The archetype appears to be designed such that the findings can only be expressed with a limited set of attributes \- color, location, shape, etc\. \- things specific to the archetypes Inspection, Auscultation, Percussion and Palpation This is the hierarchy \(or part of it\) exam    \-\- normal statements    \-\-\-\-\- normal statement    \-\- clinical description    \-\- findings    \-\-\-\-\- detail    \-\-\-\-\-\-\-\-\- exam\-generic exam\-generic    \-\- object    \-\- normal statements    \-\-\-\-\- normal statement    \-\- clinical description    \-\- findings    \-\-\-\-\- inspection    \-\-\-\-\- auscultation    \-\-\-\-\- percussion    \-\-\-\-\- palpation    \-\-\-\-\-\-\-\-\- detail    \-\-\-\-\-\-\-\-\-\-\-\-\- exam\-generic inspection \-\- findings \-\-\-\-\- color description \-\-\-\-\- location \-\-\-\-\- shape or distribution \-\-\-\-\- edge \-\-\-\-\- translucent \-\-\-\-\- detail \-\-\-\-\-\-\-\-\- exam What I was hoping to find was a free text clinical description under findings that could be used in lieu of the specialized archetypes i\.e\.    \-\- normal statements    \-\-\-\-\- normal statement    \-\- clinical description    \-\- findings    \-\-\-\-\- findings description <<<<<\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-    \-\-\-\-\- detail    \-\-\-\-\-\-\-\-\- exam\-generic thanks\! Greg --- ## Post #2 by @ian.mcnicoll Hi Greg, The clinical description element, which is replicated in the inspection, palpation and ausculation cluster archetypes should be used to carry any free text. I'm not sure I can see the semantic difference between 'clinical description' and 'findings/findings description' although I agree that the latter is slightly tidier from a human readability perspective. Do you have a particular use case in mind? Regards, Ian Dr Ian McNicoll office / fax +44(0)141 560 4657 mobile +44 (0)775 209 7859 skype ianmcnicoll [ian@mcmi.co.uk](mailto:ian@mcmi.co.uk) Clinical Analyst - Ocean Informatics [ian.mcnicoll@oceaninformatics.com](mailto:ian.mcnicoll@oceaninformatics.com) Consultant - IRIS GP Accounts [ian@gpacc.co.uk](mailto:ian@gpacc.co.uk) Member of BCS Primary Health Care Specialist Group – [www.phcsg.org](http://www.phcsg.org) 2008/10/23 Greg Caulton <[caultonpos@gmail.com](mailto:caultonpos@gmail.com)> --- ## Post #3 by @Greg_Caulton > > 2008/10/23 Greg Caulton <caultonpos at gmail\.com> > > > > I have an Archetype question on openEHR\-EHR\-CLUSTER\.exam\.v1 > > > > The archetype appears to be designed such that the findings can only > > be expressed with a limited set of attributes \- color, location, > > shape, etc\. \- things specific to the archetypes Inspection, > > Auscultation, Percussion and Palpation > > > > This is the hierarchy \(or part of it\) > > > > exam > > \-\- normal statements > > \-\-\-\-\- normal statement > > \-\- clinical description > > \-\- findings > > \-\-\-\-\- detail > > \-\-\-\-\-\-\-\-\- exam\-generic > > > > > > exam\-generic > > \-\- object > > \-\- normal statements > > \-\-\-\-\- normal statement > > \-\- clinical description > > \-\- findings > > \-\-\-\-\- inspection > > \-\-\-\-\- auscultation > > \-\-\-\-\- percussion > > \-\-\-\-\- palpation > > \-\-\-\-\-\-\-\-\- detail > > \-\-\-\-\-\-\-\-\-\-\-\-\- exam\-generic > > > > > > inspection > > \-\- findings > > \-\-\-\-\- color description > > \-\-\-\-\- location > > \-\-\-\-\- shape or distribution > > \-\-\-\-\- edge > > \-\-\-\-\- translucent > > \-\-\-\-\- detail > > \-\-\-\-\-\-\-\-\- exam > > > > > > What I was hoping to find was a free text clinical description under > > findings that could be used in lieu of the specialized archetypes > > > > i\.e\. > > > > \-\- normal statements > > \-\-\-\-\- normal statement > > \-\- clinical description > > \-\- findings > > \-\-\-\-\- findings description <<<<<\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\- > > \-\-\-\-\- detail > > \-\-\-\-\-\-\-\-\- exam\-generic > > > > thanks\! > > > > Greg > Hi Greg, > > The clinical description element, which is replicated in the inspection, > palpation and ausculation cluster archetypes should be used to carry any > free text\. > > I'm not sure I can see the semantic difference between 'clinical > description' and > 'findings/findings description' although I agree that the latter is slightly > tidier from a human readability perspective\. > > Do you have a particular use case in mind? > > Regards, > > Ian > > Dr Ian McNicoll > office / fax \+44\(0\)141 560 4657 > mobile \+44 \(0\)775 209 7859 > skype ianmcnicoll > ian at mcmi\.co\.uk > > Clinical Analyst \- Ocean Informatics ian\.mcnicoll at oceaninformatics\.com > > Consultant \- IRIS GP Accounts ian at gpacc\.co\.uk > > Member of BCS Primary Health Care Specialist Group – www\.phcsg\.org Thanks that does help, the use case is building a form to represent this example --- **Canonical:** https://discourse.openehr.org/t/general-examination-archetype/12583 **Original content:** https://discourse.openehr.org/t/general-examination-archetype/12583