ARCHETYPE Imaging finding (openEHR-EHR-CLUSTER.imaging_finding.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_finding.v0
ConceptImaging finding
DescriptionA significant clinical finding identified by radiological imaging techniques.
UseUse to record details about a single significant positive or negative clinical finding identified by radiological imaging techniques, and not otherwise modelled in specific imaging examination archetypes per body site. This archetype has been designed to be nested within the 'Imaging findings' SLOT in the OBSERVATION.imaging_exam_result or in one of the relevant CLUSTER.imaging_exam family of archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. While common findings anticipated and associated with each body site are modelled explicitly in the the CLUSTER.imaging_exam family of specialised archetypes, this archetype provides a generic pattern to model simple details about any significant clinical finding at any body site.
MisuseNot to be used to record clinical findings already modelled within the family of specialised CLUSTER.imaging_exam archetypes relevant for the identified body site.
PurposeTo record details about a significant clinical finding identified by radiological imaging techniques, not otherwise modelled in specific imaging examination archetypes per body site.
ReferencesPathology Test Result, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-27]. No longer available.

Pathology (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 May 29 [cited 2011 Jul 11]; No longer available.

Laboratory Technical Framework, Volume 3: Content, Revision 3.0 [Internet]. USA: IHE International; 2011 May 19; [cited 2011 Jul 11]. Available from: https://www.ihe.net/Technical_Framework/upload/IHE_Lab_TF_Rev3-0_Vol3_FT_2011-05-19.pdf

Hl7 FHIR Observation resource: HL7 [Internet]; [cited 2017 Jun 27]. Available from http://www.hl7.org/implement/standards/fhir/observation.html
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-27
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2020-03-27
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=Pathology Test Result, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-27]. No longer available. Pathology (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 May 29 [cited 2011 Jul 11]; No longer available. Laboratory Technical Framework, Volume 3: Content, Revision 3.0 [Internet]. USA: IHE International; 2011 May 19; [cited 2011 Jul 11]. Available from: https://www.ihe.net/Technical_Framework/upload/IHE_Lab_TF_Rev3-0_Vol3_FT_2011-05-19.pdf Hl7 FHIR Observation resource: HL7 [Internet]; [cited 2017 Jun 27]. Available from http://www.hl7.org/implement/standards/fhir/observation.html, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=0F9CA038049D647A294F5CE1F6A3C38C, build_uid=55cd1a87-5684-4be4-bd7a-11f8a522e46d, revision=0.0.1-alpha}
Keywordslaboratory, pathology, analyte, constituent, result
Lifecyclein_development
UID670088a0-ca0b-469f-ad01-9724c24e7354
Language useden
Citeable Identifier1246.145.1518
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A significant clinical finding identified by radiological imaging techniques., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Heidi Aursand, Oslo universitetssykehus, Norway
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
SB Bhattacharyya, Sudisa Consultancy Services, India
Fatemeh Chalabianloo, Helse Bergen, Norway
Anca Heyd, DIPS ASA, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Nasjonal IKT, Norway
Silje Kaada, Helse-Bergen, Avdeling for immunologi og transfusjonsmedisin, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway
Liv Laugen, Oslo universitetssykehus, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ole Martin Sand, DIPS ASA, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Paul Miller, SCIMP NHS Scotland, United Kingdom
Andrej Orel, Marand d.o.o., Slovenia
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Norwegian Review Summary, Nasjonal IKT HF, Norway
Line Sæle, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Wouter Zanen, Eurotranplant, Netherlands
Lin Zhang, Taikang Insurance Group, China, originalLanguage=en, translators=German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
Swedish: Åsa Skagerhult, Linda Aulin, Region Östergötland, Region Stockholm, asa.skagerhult@regionostergotland.se, linda.aulin@sll.se
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={description=[], state=[], identities=[], data=[], target=[], source=[], relationships=[], provider=[], protocol=[], details=[], other_participations=[], activities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0024], code=at0024, itemType=ELEMENT, level=1, text=Finding, description=Identification of the significant clinical finding, by name., comment=Coding with an external terminology is strongly recommended. For example: free fluid; or abscess., uncommonOntologyItems={hl7v2_mapping=OBX.3, fhir_mapping=Observation.code}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Presence?, description=The presence or absence of the significant finding., comment=null, uncommonOntologyItems={hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8, fhir_mapping=Observation.value[x]}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The finding is observed in the image.]
  • Absent [The finding is not observed in the image.]
  • Indeterminate [It is not possible to determine if the finding is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0028], code=at0028, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description about the observed clinical finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0033], code=at0033, itemType=ELEMENT, level=1, text=Body site, description=Simple description of anatomical location of the finding., comment=For example: Pouch of Douglas., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0034], code=at0034, itemType=SLOT, level=1, text=Structured body site, description=Structured details about the anatomical location of the finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=SLOT, level=1, text=Structured detail, description=Additional structured detail about the finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the clinical finding, not captured in other fields., comment=null, uncommonOntologyItems={hl7v2_mapping=NTE.3, fhir_mapping=Observation.note}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], events=[], contacts=[], capabilities=[], ism_transition=[], credentials=[], context=[], content=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0024], code=at0024, itemType=ELEMENT, level=1, text=Finding, description=Identification of the significant clinical finding, by name., comment=Coding with an external terminology is strongly recommended. For example: free fluid; or abscess., uncommonOntologyItems={hl7v2_mapping=OBX.3, fhir_mapping=Observation.code}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Presence?, description=The presence or absence of the significant finding., comment=null, uncommonOntologyItems={hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8, fhir_mapping=Observation.value[x]}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The finding is observed in the image.]
  • Absent [The finding is not observed in the image.]
  • Indeterminate [It is not possible to determine if the finding is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0028], code=at0028, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description about the observed clinical finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0033], code=at0033, itemType=ELEMENT, level=1, text=Body site, description=Simple description of anatomical location of the finding., comment=For example: Pouch of Douglas., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0034], code=at0034, itemType=SLOT, level=1, text=Structured body site, description=Structured details about the anatomical location of the finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=SLOT, level=1, text=Structured detail, description=Additional structured detail about the finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the clinical finding, not captured in other fields., comment=null, uncommonOntologyItems={hl7v2_mapping=NTE.3, fhir_mapping=Observation.note}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]