ARCHETYPE Imaging examination of a pregnant uterus (openEHR-EHR-CLUSTER.imaging_exam-pregnant_uterus.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_exam-pregnant_uterus.v0
ConceptImaging examination of a pregnant uterus
DescriptionFindings on radiological examination of a pregnant uterus.
UseUse to record the findings on radiological examination of a pregnant uterus, and their interpretation. The intended scope for this archetype is to eventually record all detailed findings on radiological examination of a pregnant uterus using any modality. 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-uterus 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.
MisuseNot to be used to record non pregnancy-related imaging examination findings for the uterus. Use other archetypes from the CLUSTER.imaging_exam-uterus for this purpose. Not to be used to record imaging examination findings for any body structure or region other than a pregnant uterus. Use other archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record the estimated gestational age. Use OBSERVATION.gestation 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.
PurposeTo record the findings on radiological examination of a pregnant uterus, and their interpretation.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2021-11-24
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2021-11-24
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: openEHR Foundation
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • MD5-CAM-1.0.1: 322D2359232BA8B624E16264C9CCE7BF
  • Build Uid: a7223c37-1c4a-44d1-8d7b-e227033c853f
  • 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
Keywords
Lifecyclein_development
UID0ea59022-c082-4a63-8866-a05c2036f773
Language useden
Citeable Identifier1246.145.2805
Revision Number0.0.1-alpha
items
Body structureBody 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.
  • Pregnant uterus
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.
Gestational sac presenceGestational sac presence: Presence of a gestational sac within the uterus.
  • Present [A gestational sac is observed.]
  • Absent [No gestational sac is observed.]
  • Indeterminate [It is not possible to determine if a gestational sac is present or absent.]
Number of gestational sacsNumber of gestational sacs: Number of gestational sacs observed in the uterus.
Gestational sac findingsGestational sac findings: Structured details about a single observed gestational sac within the uterus.
Include:
openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v1 and specialisations
Number of foetusesNumber of foetuses: Number of fetuses observed in the uterus.
AmnionicityAmnionicity: The number of amnions (inner membranes) that surround the embryos or fetuses in a multiple pregnancy.
Choice of:
  •  Count
  •  Coded Text
    • Monoamniotic [One amniotic sac is observed.]
    • Diamniotic [Two amniotic sacs are observed.]
    • Triamniotic [Three amniotic sacs are observed.]
    • Quadriamniotic [Four amniotic sacs are observed.]
ChorionicityChorionicity: The number of placental masses observed in a multiple pregnancy.
Choice of:
  •  Count
  •  Coded Text
    • Monochorionic [One chorion or placenta is observed.]
    • Dichorionic [Two chorions or placentas are observed.]
    • Trichorionic [Three chorions or placentas are observed.]
    • Quadrichorionic [Four chorions or placentas are observed.]
Placental findingsPlacental findings: Structured details about a single placenta/placental mass.
Include:
openEHR-EHR-CLUSTER.imaging_exam-placenta.v0 and specialisations
Fetal findingsFetal findings: Structured details about a single foetus.
Include:
openEHR-EHR-CLUSTER.imaging_exam-foetus.v1 and specialisations
Other contributorsMarit 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
Anne Helbig, MD PhD, Oslo University Hospital, 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
Liv Laugen, ​Oslo University Hospital, Norway, Norway (openEHR Editor)
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
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
  • German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
  • Norwegian Bokmål: Peter Fedorcsak, Vebjørn Arntzen, University of Oslo, Oslo University Hospital, peterfe@uio.no, varntzen@ous-hf.no