| ARCHETYPE ID | openEHR-EHR-CLUSTER.imaging_exam-scrotum.v0 |
|---|---|
| Concept | Imaging examination of the scrotum |
| Description | Findings observed in an imaging examination targeting the scrotum, using radiographic techniques. |
| Use | Use to record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting the scrotum. This archetype has been designed to be used in the 'Structured imaging findings' SLOT within the OBSERVATION.imaging_exam_result archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Additional details' SLOT within this archetype to record additional nested levels of structured imaging findings for related body substructures or site-specific findings. |
| Misuse | Not to be used to record findings outside the specified body structure or region. 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 a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting the scrotum. |
| 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 | |
| Lifecycle | in_development |
| UID | 4fea727f-be22-464d-a6a9-0a4cfb7ede5c |
| Language used | en |
| Citeable Identifier | 1246.145.2640 |
| Revision Number | 0.0.1-alpha |
| items | |
| Body structure | Body structure: Identification of the body structure or region examined.
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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. |
| 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_ 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 | Vebjørn Arntzen, Oslo University Hospital Liv Laugen, Oslo University Hospital Peter Fedorcsak, Oslo University Hospital |
| Translators |
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