| ARCHETYPE ID | openEHR-EHR-CLUSTER.imaging_exam_anomaly.v0 |
|---|---|
| Concept | Imaging examination of an anomaly |
| Description | An incidental or ambiguous finding of an anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region. |
| Use | Use to record an incidental or ambiguous finding of a single anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region. If more than one anomaly has been identified within the context of the same body structure or region, use a separate instance of this archetype to describe each anomaly. The intended scope for this archetype is to record detailed findings about an anomaly using any modality. It is anticipated that specific CLUSTER archetypes will be developed in the future to record common abnormal radiological findings, such as fractures. If a specific archetype to record the anomaly is not available, use this generic archetype to record relevant findings. Until the specific archetypes are developed, current use cases include, but are not limited to:
This archetype is designed to be nested within the 'Additional details' SLOT in any of the CLUSTER.imaging_exam family of archetypes which will provide the context for the anomaly, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. |
| Misuse | Not to be used to record normal or abnormal findings that are expected for a specified imaging examination. Use specialised archetypes from the CLUSTER.imaging_exam family or the generic CLUSTER.imaging_exam archetype 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 OBERSERVATION.imaging_exam_result for this purpose. For example, comments on the study quality, differential diagnoses, and overall impression. |
| Purpose | To record an incidental or ambiguous finding of a single anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region. |
| 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 | lesion, mass, tumour, tumor, nodule, cyst, calculus, thrombosus, abnormality, anomaly |
| Lifecycle | in_development |
| UID | 4850bc1a-b1bb-4eda-8390-776f77690ebb |
| Language used | en |
| Citeable Identifier | 1246.145.1744 |
| Revision Number | 0.0.1-alpha |
| Archetype Concept Comment | For example: a cyst or mass; a thrombosis; a polyp; a calculus or a foreign body. |
| items | |
| 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. |
| 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. |
| Label | Label: A label for the anomaly. Use to differentiate one anomaly from another when there is more than one present within the context of the same body structure or region. |
| Type | Type: The type of anomaly. Coding of the anomaly with an external terminology is preferred, where possible. For example, a cyst or nodule. |
| Shape | Shape: The contour or silhouette of the anomaly. |
| Physical properties | Physical properties: A physical properties of the anomaly. Include: All not explicitly excluded archetypes |
| Texture | Texture: Description of the texture or consistency of the anomaly. |
| Margin | Margin: The border of the anomaly. For example: 'Well-defined' or 'Diffuse'. |
| Calcification | Calcification: Presence of calcification in the anomaly.
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| Calcification description | Calcification description: Description about the pattern of calcification observed. The pattern of calcification can be coded if desired. |
| Effect | Effect: Description about the effect of the anomaly on surrounding structures. For example: presence of an echo shadow behind the anomaly or that it is distorting adjacent structures. |
| Vascularisation description | Vascularisation description: Description about the blood flow related to to the anomaly. |
| Comment | Comment: Additional narrative about the imaging findings of the anomaly, not captured in other fields. |
| 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_ |
| 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 Jesper Blomquist, Haraldsplass Diakonale Sykehus, Norway 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 Heather Grain, Llewelyn Grain Informatics, Australia Johan Gustav Bellika, Norwegian Centre for Integrated Care and Telemedicine, Norway Anca Heyd, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør) 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) Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Arunakiry Natarajan, medondo, Germany Svenne Naumann, Finnmarkssykehuset, Norway Mikael Nyström, Cambio Healthcare Systems AB, Sweden Bjørn Næss, DIPS ASA, Norway Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway Natalia Strauch, Medizinische Hochschule Hannover, Germany Norwegian Review Summary, Norwegian Public Hospitals, Norway John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) |
| Translators |
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