| ARCHETYPE ID | openEHR-EHR-CLUSTER.imaging_exam.v1 |
|---|---|
| Concept | Imaging examination of a body structure |
| Description | Findings on radiological examination of a specified body structure or region. |
| Use | Use to record the findings on radiological examination of a specified body structure or region, and their interpretation. The intended scope for the CLUSTER.imaging_exam family of archetypes to be used to record all detailed findings on radiological examination. The family of specialised archetypes are derived from this generic parent archetype, CLUSTER.imaging_exam, designed as a universal pattern for recording any findings in any specified body structure or region and using any modality. This archetype and its related family of specialisations are designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result or within the 'Additional details' SLOT in other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype or its specialisations need to be extended with further levels of detailed findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT. Each structure- or region-specific specialisation of this parent archetype is intended to be inclusive of all reasonably anticipated and relevant findings. For example, the CLUSTER.imaging_exam-ovary will support recording of all findings that would be expected in reporting on imaging of the ovary using any radiological modality, including the size of the ovary, largest follicle size and the diameter and description of specific follicles. Similarly, CLUSTER.imaging_exam-lymph_node_group will contain data elements required to record specific findings of a lymph node group, including its precise or relative location in the body and the number of lymph nodes in the group. If an appropriate specialisation is not available for a body structure or region, this generic archetype can be used to record all relevant findings, including identification of the structure or region. |
| Misuse | Not to be used to record findings observed outside the identified body structure or region. Use a separate instance of one or more archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record details related to the overall findings, context or technical details related to a complete imaging examination test result. Use the OBSERVATION.imaging_exam_result for this purpose. For example, comments on the study quality, differential diagnoses, and overall impression. |
| Purpose | To record the findings on radiological examination of a specified body structure or region, and their interpretation. |
| References | |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2021-11-24 |
| Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2021-11-24 |
| Other Details (Language Independent) |
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| Keywords | finding, imaging, body, system, structure, region, observation, diagnostic, radiology, image |
| Lifecycle | published |
| UID | ba15da73-273a-4dbd-92f4-bfde28d1872c |
| Language used | en |
| Citeable Identifier | 1246.145.1743 |
| Revision Number | 1.1.3 |
| items | |
| Body structure | Body structure: Identification of the body structure or region examined. For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant. |
| Body site | Body site: Identification of the area of the body under examination. For example: a lymph node group (body structure) which found in the 'Right axilla'. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable. If the body site has been fully identified in the 'Body structure' data element, this data element becomes redundant. |
| Structured body site | Structured body site: Structured details about the area of the body under examination. For example: details about a relative anatomical location, such as '2cm distal to the appendix'. If the body site has been fully identified in the 'Body structure' or 'Body site' data elements, then this SLOT becomes redundant. Include: openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ |
| Imaging findings | Imaging findings: Narrative description of the imaging findings observed during this examination. |
| Additional details | Additional details: Additional structured details about imaging findings for the identified body structure or region, or findings of related structures. Include: openEHR-EHR-CLUSTER.imaging_ openEHR-EHR-CLUSTER.imaging_ openEHR-EHR-CLUSTER.imaging_ |
| Impression | Impression: Single word, phrase or brief description that represents the clinical meaning and significance of all imaging findings for the identified body structure. Also referred to as 'Interpretation' or 'Opinion'. For example: 'No abnormality detected' or 'Free fluid present'. Coding of the 'Impression' with a terminology is permitted, if useful. Multiple occurrences allow for more than one coded impression. A narrative description may include a comparison with previous studies of the identified body structure, if appropriate. |
| Comment | Comment: Additional narrative about the imaging findings of the body structure, not captured in other fields. |
| Other contributors | Andreas Abildgaard, OUS, Norway Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India Randi Brendberg, Helse Nord RHF, Norway Gunn Elin Blakkisrud, DIPS ASA, Norway Peter Fedorcsak, University of Oslo, Norway (openEHR Editor) Kåre Flø, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Kija Indrearne, Helse Bergen, Norway Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør) Aud Jorunn Mjelstad, Helse Bergen, Norway Anjali Kulkarni, Karkinos, India Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Liv Laugen, Oslo University Hospital, Norway, Norway (openEHR Editor) Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Svenne Naumann, Finnmarkssykehuset, Norway Mikael Nyström, Cambio Healthcare Systems AB, Sweden Bjørn Næss, DIPS ASA, Norway Natalia Strauch, Medizinische Hochschule Hannover, Germany Norwegian Review Summary, Norwegian Public Hospitals, Norway John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) |
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