ARCHETYPE Anatomical pathology examination (openEHR-EHR-CLUSTER.anatomical_pathology_exam.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.anatomical_pathology_exam.v0
ConceptAnatomical pathology examination
DescriptionFindings and interpretation of an anatomical pathology examination performed on tissues and body fluids.
UseUse to record any anatomical pathology test result, including microscopic and macroscopic examinations of tissues, cells or body fluids. In some locations the terms "histopathology" and "cytology" may be used in place of "anatomical pathology". This archetype is designed specifically to be used in the "Test result" SLOT within the OBSERVATION.laboratory_test_result archetype, but may also be used within other ENTRY class archetypes where appropriate.
MisuseNot to be used for reporting other types of laboratory test results, for example biochemistry or haematology. Not to be used to record an autopsy report, although tests on some specimens that are collected during an autopsy may be represented using this archetype.
PurposeTo record the findings and interpretation of anatomical pathology tests performed on tissues, cells and body fluids.
ReferencesDerived from Histopathology test, Draft Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-11-29]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.2195
Copyright© openEHR Foundation, Nasjonal IKT HF
AuthorsAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT HF
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2016-11-23
Other Details LanguageAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT HF
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2016-11-23
OtherDetails 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=Nasjonal IKT, references=Derived from Histopathology test, Draft Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-11-29]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.2195, original_namespace=no.nasjonalikt, original_publisher=Nasjonal IKT, custodian_namespace=no.nasjonalikt, MD5-CAM-1.0.1=F83BDA5FF0E2EADC298D3A4562C5F5B0, build_uid=02e36c83-f609-4ab7-ad20-acc47156426b, revision=0.0.1-alpha}
Keywordshistopathology, cytology, pathology
Lifecyclein_development
UID5cace535-184c-44d6-bd8b-673e7e5b3664
Language useden
Citeable Identifier1246.145.33
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings and interpretation of an anatomical pathology examination performed on tissues and body fluids., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo universitetssykehus, Norway
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør)
Kristin Eik, Kreftregisteret, Norway
Anca Heyd, DIPS ASA, Norway
Sabine Leh, Helse-Bergen, Norway (Nasjonal IKT redaktør)
Heather Leslie, Ocean Informatics, Australia (Nasjonal IKT redaktør)
Jan-Arne Ludvigsen, DIPS ASA, Norway
Ole Martin Sand, DIPS ASA, Norway
Ian McNicoll, Ocean Informatics, United Kingdom (Nasjonal IKT redaktør)
Bjørn Næss, DIPS ASA, Norway
Sveinung Sørbye, UNN HF, Norway
John Tore Valand, Helse Bergen HF, Norway
Torleif Trydal, Fürst AS, Norway
Johan Bjerner, Fürst AS, Norway
Nils Petter Tveranger, Helse Vest IKT AS, Norway, originalLanguage=en, translators=German: Aurelie Tomczak, Institute of Pathology, University Hospital Heidelberg, au.tomczak@yahoo.com
Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={relationships=[], identities=[], provider=[], content=[], events=[], data=[], credentials=[], capabilities=[], target=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0019], code=at0019, itemType=ELEMENT, level=1, text=Examination type, description=Identification of the type of anatomical pathology examination performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Macroscopic examination [Findings recorded on examination of a gross specimen.]
    • Microscopic examination [Findings recorded after microsopic examination.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=CLUSTER, level=1, text=Anatomical pathology finding, description=Details of an individual anatomical pathology finding, often related to a specific anatomical location or specimen., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0023], code=at0023, itemType=ELEMENT, level=2, text=Finding label, description=A text label for the specific finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0008], code=at0008, itemType=ELEMENT, level=2, text=Finding description, description=A narrative description of the anatomical pathology finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0009], code=at0009, itemType=SLOT, level=2, text=Structured findings, description=Detailed structured findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=Pathology interpretation, description=Single word, phrase of brief description representing the interpretation of the anatomical pathology finding. A coded term is preferred., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0022], code=at0022, itemType=SLOT, level=2, text=Multimedia representation, description=Digital image, video or diagram representing the examination., comment=Multiple formats are allowed but they should represent equivalent clinical content., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v0 and specialisations Or
openEHR-EHR-CLUSTER.multimedia.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0017], code=at0017, itemType=ELEMENT, level=2, text=Specimen container ID, description=Reference ID, URI or text for a specimen container related to this finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  URI
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0006], code=at0006, itemType=ELEMENT, level=2, text=Tissue available, description=True if the tissue is available for examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=ELEMENT, level=1, text=Examination description, description=A narrative description of the entire anatomical pathology examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Specimen container ID, description=Reference ID, URI or text for a specimen containera related to this finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  URI
  •  Text
, extendedValues=null]], protocol=[], ism_transition=[], contacts=[], activities=[], context=[], other_participations=[], state=[], details=[], description=[], source=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0019], code=at0019, itemType=ELEMENT, level=1, text=Examination type, description=Identification of the type of anatomical pathology examination performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Macroscopic examination [Findings recorded on examination of a gross specimen.]
    • Microscopic examination [Findings recorded after microsopic examination.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=CLUSTER, level=1, text=Anatomical pathology finding, description=Details of an individual anatomical pathology finding, often related to a specific anatomical location or specimen., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0023], code=at0023, itemType=ELEMENT, level=2, text=Finding label, description=A text label for the specific finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0008], code=at0008, itemType=ELEMENT, level=2, text=Finding description, description=A narrative description of the anatomical pathology finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0009], code=at0009, itemType=SLOT, level=2, text=Structured findings, description=Detailed structured findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=Pathology interpretation, description=Single word, phrase of brief description representing the interpretation of the anatomical pathology finding. A coded term is preferred., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0022], code=at0022, itemType=SLOT, level=2, text=Multimedia representation, description=Digital image, video or diagram representing the examination., comment=Multiple formats are allowed but they should represent equivalent clinical content., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v0 and specialisations Or
openEHR-EHR-CLUSTER.multimedia.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0017], code=at0017, itemType=ELEMENT, level=2, text=Specimen container ID, description=Reference ID, URI or text for a specimen container related to this finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  URI
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005]/items[at0006], code=at0006, itemType=ELEMENT, level=2, text=Tissue available, description=True if the tissue is available for examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=ELEMENT, level=1, text=Examination description, description=A narrative description of the entire anatomical pathology examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0018], code=at0018, itemType=ELEMENT, level=1, text=Specimen container ID, description=Reference ID, URI or text for a specimen containera related to this finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Identifier
  •  URI
  •  Text
, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]