Autopsy examination: Observation

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Comments to Ocean Informatics

Findings at autopsy

Id: openEHR-EHR-OBSERVATION.autopsy.v1
Reference model: EHR
ADL

History

Protocol

Data

State

Data: TREE

Concept	Description	Type	Cardinality	Values
Clinical	Statement about the clinical findings prior to death	*Text*	optional 0..1	Free or coded text
External examination	Findings on external examination	*Text*	optional 0..1	Free or coded text

Internal examination, Collection of statements about particular systems. Cluster (0..1) optional

Concept	Description	Type	Cardinality	Values
System	Findings relating to different body systems	*Text* *Runtime name constraint:* {Cardiovascular system, Respiratory system, Gastro-intestinal system, Reticulo-Endothelial system, Genito-urinary system, Endocrine System, Central nervous system, Musculoskeletal system}	optional, repeating 0..*	Free or coded text

Microscopic examination, Findings on microscopy organised by organ. Cluster (0..1) optional

Concept	Description	Type	Cardinality	Values
Organ	Findings relating to biopsies of individual organs	*Text* *Runtime name constraint:* {Adrenals, Brain, Heart, Kidneys, Liver, Lungs, Pancreas, Pituitary, Small bowel, Spleen, Thyroid, Vertebra}	optional, repeating 0..*	Free or coded text

Events: HISTORY

Events	Description	Constraints	Values
Any event	*	PointInTime 0..*

Supported by the General Practice Computing Group of Australia through funding from the Commonwealth Department of Health and Ageing