normal statements
Normal statements are a feature of many examination archetypes. By having a repeatable element for normal statements it allows application vendors and clinicians to make very diverse statements about the examination at varying levels of granularity but classifying the finding as normal.
Consider an examination of the heart.
The person may record normal statements such as:
- Normal
- Normal examination
- No bruits
- No pericardic rub
- No evidence of heart enlargement
- 2 HS, no bruits
- No murmurs
While all of these may be coded in SNOMED the description for no bruits is O/E no cardiac murmur. As the archetype is describing examination of the heart, clinicians are going to find such statements, especially when multiple, very heavy handed.
A further reason to take this approach is that the clinician can categorise the statement as covering normality which is probably the key classification of importance. Normal statements can obviously be made with abnormal findings in other parts of the archetype. If the only data collected in an exam are normal statements then it could reasonably be assumed that the findings were normal. This may require some validation in critical situations.