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The base pattern of the single OBSERVATION + multiple CLUSTER pattern appears sound and has withstood early implementations. Admittedly, these initial implementations have largely been fairly light on requirements for exam detail, and using SNOMED CT to define the 'System or structure examined' in the generic CLUSTER.exam has been adequate.
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- Base clinical pattern consists of the 'Physical examination findings' OBSERVATION.exam nesting one to many CLUSTER.exam archetypes within the 'Examination detail' SLOT. Note: if the state of the patient changes, or a different devices are used, then this pattern may need to be represented for each state or device variation.
- Clinical pattern for the minimum generic content for the CLUSTER.exam, now agreed and published. SNOMED CT, or similar, bindings to be applied to the 'System or structure examined' data element where possible.
- Acknowledgement that we will need to create archetypes that capture additional detailed content that is specific for each examination.
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