| ARCHETYPE ID | openEHR-EHR-CLUSTER.imaging_exam-fallopian_tube.v1 |
|---|---|
| Concept | Imaging examination of a fallopian tube |
| Description | Findings on radiological examination of a single fallopian tube. |
| Use | Use to record the findings on radiological examination of a single fallopian tube, and their interpretation. The intended scope for this archetype is to eventually record all detailed findings on radiological examination about the fallopian tube using any modality, including examinations using contrast, such as Hysterosalpingography (HSG) or Hysterosalpingo-Contrast Sonography (HyCoSy). It is anticipated that further data elements may be added as requirements are identified and confirmed. This archetype is designed to be nested within the 'Additional details' SLOT in the CLUSTER.imaging_exam-uterine_body, the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result or within other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype needs to be extended with further levels of structured findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT. Details about medication or contrast medium administered as part of an imaging examination will be recorded using the ACTION.medication archetype, usually linked from the 'Procedure' data element within the OBSERVATION.imaging_exam_result archetype. A summary of any issues arising during the procedure, such as an increased resistance observed while flushing with contrast, should be recorded in the 'Comment' data element within this archetype or the 'Procedure summary' data element within the OBSERVATION.imaging_exam_result. Details related to the procedure can be recorded in a separate Procedure report using the ACTION.procedure archetype. |
| Misuse | Not to be used to record imaging examination findings for any body structure or region other than a single fallopian tube. Use other 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 OBERSERVATION.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 single fallopian tube, 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 | fluroscopy, hysterosalpingogram, contrast, saline, hycosy, hsg, sonography, ultrasound, tube, sactosalpinx, hydrosalpinx, pyosalpinx |
| Lifecycle | published |
| UID | 0f57bc87-f0a2-48c9-b3cd-7d97b81c942d |
| Language used | en |
| Citeable Identifier | 1246.145.2420 |
| Revision Number | 1.0.1 |
| items | |
| Body structure | Body structure: Identification of the body structure or region examined. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT becomes redundant.
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| 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. |
| Patency | Patency: Assessment of the patency of the fallopian tube.
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| Gestational sac presence | Gestational sac presence: Presence of a gestational sac within the identified fallopian tube.
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| 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. |
| Gestational sac details | Gestational sac details: Structured details about an observed gestational sac within the fallopian tube. Include: openEHR-EHR-CLUSTER.imaging_ |
| Other contributors | 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 Peter Fedorcsak, University of Oslo, Norway (openEHR Editor) Heather Grain, Llewelyn Grain Informatics, Australia Anca Heyd, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør) 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) Mikael Nyström, Cambio Healthcare Systems AB, Sweden Norwegian Review Summary, Norwegian Public Hospitals, Norway Tina Tellum, Oslo Universitetssykehus, Norway John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) Ina Wille, Helse-Vest RHF, Norway |
| Translators |
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