ARCHETYPE Imaging examination of the heart (openEHR-EHR-CLUSTER.imaging_exam-heart.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_exam-heart.v0
ConceptImaging examination of the heart
DescriptionFindings on radiological examination of the heart.
UseUse to record the findings on radiological examination of the heart, and their interpretation. 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. The design of this archetype is intended to be inclusive of all reasonably anticipated and relevant findings.
MisuseNot 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.
PurposeTo record the findings on radiological examination of the heart, and their interpretation.
ReferencesDerived from: <Add reference to original resource here>
Copyright© openEHR Foundation, HiGHmed
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2024-06-24
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2024-06-24
Other Details (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: HiGHmed
  • References: Derived from:
  • Original Namespace: org.highmed
  • Original Publisher: HiGHmed
  • Custodian Namespace: org.highmed
  • MD5-CAM-1.0.1: 98B86245351C48D3B2482FBF050331F2
  • Build Uid: 209da4dd-e4fe-4346-945c-96820dae7df7
  • Ip Acknowledgements: This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.
  • Revision: 0.0.1-alpha
Keywordsheart, valve, ventricle, aorta, aortic, pulmonary, tricuspid, mitral, atrium, atria
Lifecyclein_development
UIDbff5ea9f-33e3-4fa4-88f0-c4091394c071
Language useden
Citeable Identifier1246.145.2422
Revision Number0.0.1-alpha
items
Body structureBody 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.
  • Heart
Body siteBody 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 siteStructured 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_location.v1 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_relative.v2 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations
Imaging findingsImaging findings: Narrative description of the imaging findings observed during this examination.
Additional detailsAdditional details: Additional structured details about imaging findings for the identified body structure or region, or findings of related structures.
Include:
openEHR-EHR-CLUSTER.imaging_exam-lymph_node.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lymph_node_group.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lesion.v0 and specialisations
ImpressionImpression: 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.
CommentComment: Additional narrative about the imaging findings of the body structure, not captured in other fields.
Relative ventricular sizeRelative ventricular size: Description of the comparative size of both cardiac ventricles relative to established normal ranges.
Choice of:
  •  Coded Text
    • Normal
    • Enlarged
  •  Text
Valves normal?Valves normal?: Overarching assessment about the condition and functionality of all heart valves, reflecting their structural integrity, movement, and any abnormalities observed.
Choice of:
  •  Boolean
  •  Coded Text
    • Normal [All valves appear normal.]
    • Abnormal [Valvular damage is observed.]
  •  Text
PericarditisPericarditis: Statement about the presence or absence of pericarditis.
  • Present
  • Absent
  • Indeterminate
MyocarditisMyocarditis: Statement about the presence or absence of myocarditis.
  • Present
  • Absent
  • Indeterminate
CLUSTER
CLUSTER
DV_QUANTITY
DV_QUANTITY
DV_QUANTITY
DV_QUANTITY
DV_QUANTITYDV_QUANTITY: Property: Mass
Units: >=0.0 g
CLUSTER
DV_QUANTITY
DV_QUANTITY
DV_QUANTITY
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
CLUSTER
DV_QUANTITY
CLUSTER
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
CLUSTER
DV_CODED_TEXTDV_CODED_TEXT:
  • *2-Kammerblick (2CH) (de) [*apikal (de)]
  • *4-Kammerblick (4CH) (de) [*apikal, subkostal (de)]
  • *Biplan (de)
  • *3D (de)
CLUSTER
DV_QUANTITYDV_QUANTITY: Property: Volume
Units: >=0.0 ml
DV_QUANTITYDV_QUANTITY: Property: Volume
Units: >=0.0 ml
DV_QUANTITYDV_QUANTITY: Property: Proportion
Units: >=0.0 %
DV_QUANTITY
DV_CODED_TEXTDV_CODED_TEXT:
  • *Gut (de)
  • *Leichtgradig eingeschränkt (de)
  • *Leicht- bis mittelgradig eingeschränkt (de)
  • *Mittelgradig eingeschränkt (de)
  • *Mittel- bis hochgradig eingeschränkt (de)
  • *Hochgradig eingeschränkt (de)
DV_QUANTITY
DV_QUANTITYDV_QUANTITY: Property: Length
Units: mm
CLUSTER
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_QUANTITYDV_QUANTITY: Property: Area
Units: >=0.0 cm²
DV_QUANTITYDV_QUANTITY: Property: Area
Units: >=0.0 cm²
DV_QUANTITY
DV_QUANTITY
DV_QUANTITYDV_QUANTITY: Property: Volume
Units: >=0.0 ml
DV_QUANTITY
DV_QUANTITYDV_QUANTITY: Property: Length
Units: mm
CLUSTER
DV_QUANTITYDV_QUANTITY: Property: Area
Units: >=0.0 cm²
DV_QUANTITY
DV_QUANTITYDV_QUANTITY: Property: Volume
Units: >=0.0 ml
DV_QUANTITY
CLUSTER
DV_QUANTITYDV_QUANTITY: Property: Area
Units: >=0.0 cm²
DV_QUANTITY
DV_QUANTITYDV_QUANTITY: Property: Volume
Units: >=0.0 ml
DV_QUANTITY
CLUSTER
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_CODED_TEXTDV_CODED_TEXT:
  • *Vorhanden (de)
  • *Nicht vorhanden (de)
  • *Unbestimmt (de)
DV_CODED_TEXTDV_CODED_TEXT:
  • *Vorhanden (de)
  • *Nicht vorhanden (de)
  • *Eingeschränkt vorhanden (de)
  • *Unbestimmt (de)
DV_TEXTDV_TEXT: Choice of:
  •  Text
  •  Quantity
CLUSTER
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
DV_QUANTITYDV_QUANTITY: Property: Length
Units: >=0.0 mm
CLUSTER
CLUSTER
Aortic regurgitation (AR)Aortic regurgitation (AR): Statement about the presence or absence of aortic regurgitation.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
Aortic regurgitation (AR)Aortic regurgitation (AR): Statement about the presence or absence of aortic regurgitation.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
Aortic regurgitation (AR)Aortic regurgitation (AR): Statement about the presence or absence of aortic regurgitation.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
Aortic regurgitation (AR)Aortic regurgitation (AR): Statement about the presence or absence of aortic regurgitation.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
  • *mittel- bis hochgradig (de)
  • *hochgradig (de)
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
CLUSTER
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
DV_TEXTDV_TEXT: Choice of:
  •  Text
  •  Quantity
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
DV_TEXTDV_TEXT: Choice of:
  •  Text
  •  Quantity
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
DV_TEXTDV_TEXT: Choice of:
  •  Text
  •  Quantity
CLUSTER
Aortic stenosis (AS)Aortic stenosis (AS): Statement about the presence or absence of aortic stenosis.
  • Present
  • Absent
  • Indeterminate
DV_CODED_TEXTDV_CODED_TEXT:
  • *leichtgradig (de)
  • *leicht- bis mittelgradig (de)
  • *mittelgradig (de)
DV_TEXTDV_TEXT: Choice of:
  •  Text
  •  Quantity
Other contributors
Translators
  • German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
  • Norwegian Bokmål: Vebjørn Arntzen, Oslo University Hospital, varntzen@ous-hf.no