ARCHETYPE Anatomical location (openEHR-EHR-CLUSTER.anatomical_location.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.anatomical_location.v1
ConceptAnatomical location
DescriptionA physical site on or within the human body.
UseUse to record structured and consistent details about one or more identified physical sites on, or within, the human body. This archetype is specifically designed to be used within the context of any appropriate ENTRY or CLUSTER archetypes which supply the context of the anatomical location. As a fundamental part of clinical practice, clinicians can describe anatomical locations in a myriad of complex and variable ways. In practice, some archetypes carry a single data element for carrying a simple description of body site - for example, OBSERVATION.blood_pressure and CLUSTER.symptom when describing ear pain. In this situation, where the value set is predictable and simple to define, this single data element is a very accurate and pragmatic way to record the site in the body and to query at a later date. However in the situation where the anatomical location is not well defined or needs to be determined at run-time, it may be more flexible to use this structured archetype. For example, in the situation where any symptom can be recorded without any predefined scope of the type of symptom, then allowing the use of this archetype to specifically define an anatomical location in the body may be useful. In this case the CLUSTER.symptom archetype also carries a SLOT for 'Detailed anatomical location' which can include this archetype to support maximal flexibility in recording anatomical location data. This archetype supports recording complex structured anatomical sites. For example, the apex beat of the heart is typically found at the fifth left intercostal space in the mid-clavicular line, tenderness at McBurney's point on the abdominal wall or a laceration on the palmar aspect of the proximal right thumb. A combination of the data elements in this archetype can be used to individually record each component of a postcoordinated terminology expression that represents the anatomical site. The 'Alternative structure' SLOT allows inclusion of additional archetypes that provide an alternative structure for describing the same body site, such as CLUSTER.anatomical_location_relative or CLUSTER.anatomical_location_clock, should this be required. In the situation where this archetype can only be used to name a large and/or non-specific body part, the additional use of the CLUSTER.anatomical_location_relative archetype will support recording of a more precise location - for example, 2 cm anterior to the cubital fossa of the left forearm or 4 cm below R costal margin on the chest wall in the mid-clavicular line. If this archetype is used within other archetypes where the specified subject of care is not the individual for whom the record is being created, for example a fetus in-utero, then the anatomical location will be identifying a body site on or within the fetus.
PurposeTo identify and record structured details about one or more physical sites on, or within, the human body using macroscopic anatomical terms.
ReferencesAnatomy Mapper website [Internet]. Matt Molenda, [cited 2015 Apr 27]. Available from: http://www.anatomymapper.com/.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2008-11-10
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2008-11-10
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Anatomy Mapper website [Internet]. Matt Molenda, [cited 2015 Apr 27]. Available from: http://www.anatomymapper.com/., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=8F242A3494D18872E7484433716A5FF9, build_uid=335479df-3a25-40a7-8427-560eeb811bb6, revision=1.1.1-alpha}
Keywordslocation, site, anatomical, anatomic region, topographic anatomy, macroscopic, anatomic, anatomy
Lifecyclein_development
UID2fe9e9f8-adfd-4406-878a-82b38ef498a9
Language useden
Citeable Identifier1246.145.640
Revision Number1.1.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A physical site on or within the human body., archetypeConceptComment=null, otherContributors=Grethe Almenning, Bergen kommune, Norway
Tomas Alme, DIPS, Norway
Erling Are Hole, Helse Bergen, Norway
Vebjørn Arntzen, Oslo University Hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Maria Beate Nupen, Oslo Universitetssykehus, Norway
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, Queensland Health, Australia
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain
Shahla Foozonkhah, Iran ministry of health and education, Iran
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Sebastian Garde, Ocean Informatics, Germany
Bente Gjelsvik, Helse Bergen, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean Informatics, Australia
Ingrid Heitmann, Oslo University Hospital, Norway
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Anca Heyd, DIPS ASA, Norway
Dunmail Hodkinson, Black Pear Software Ltd, UK
Lars Karlsen, DIPS ASA, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Shinji Kobayashi, Kyoto University, Japan
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Vesna Levasic, Orthopaedic Hospital Valdoltra, Slovenia
Hallvard Lærum, Norwegian Directorate of e-health, Norway
Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Erik Nissen, Cambio Healthcare Systems AB, Sweden
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Anne Pauline Anderssen, Helse Nord RHF, Norway
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Thomas Schopf, University Hospital of North-Norway, Norway
Micaela Thierley, Helse Bergen, Norway
Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)
Richard Townley-O'Neill, Australian Digital Health Agency, Australia
Dmitri Wall, Irish Skin Foundation, Ireland
Natalia Strauch, Medizinische Hochschule Hannover, Germany, originalLanguage=en, translators=German: Sarah Ballout, ballout.sarah@mh-hannover.de
Norwegian Bokmål: Lars Bitsch-Larsen, Haukeland University Hospital of Bergen, Norway, MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.
Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP, osmeire.acsanzovo@hsl.org.br
Arabic (Syria): Mona Saleh
Slovenian: Biljana Princic
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={relationships=[], identities=[], provider=[], content=[], events=[], data=[], credentials=[], capabilities=[], target=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0065], code=at0065, itemType=ELEMENT, level=1, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant., 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[at0002], code=at0002, itemType=ELEMENT, level=1, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT::272741003 | Laterality (attribute)], values=
  • Left [Left side of the body.]
    [SNOMED-CT::419161000] (Unilateral left (qualifier value))
  • Right [Right side of the body.]
    [SNOMED-CT::419465000] (Unilateral right (qualifier value))
  • Left and right [Both sides of the body.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0083], code=at0083, itemType=ELEMENT, level=1, text=Occurrence, description=One or more sides of the body., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Unilateral [One-sided.]
  • Bilateral [Two-sided.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0064], code=at0064, itemType=ELEMENT, level=1, text=Aspect, description=Qualifying detail about the specific aspect of the identified body site., comment=Use to increase precision of identification of the body site, if required. Common aspects have been included as a value set, which can be extended over time, plus a free text option. Assumes that the body is being described while in the anatomical position. For example: proximal urethra; plantar aspect of the left thumb. Multiple aspects can also be described, if required, by allowing for 0..2 occurrences. For example: a lesion may be on the left anterior/lateral (ie anterolateral) chest wall. If the 'Body site name' data element uses pre-coordinated terms that include the aspect, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Medial [Towards the midline of the body site.]
    • Lateral [Towards the side, or edge, of the body site.]
    • Superior [Above the body site, often meaning towards the head.]
    • Inferior [Below the body site, often meaning towards the feet.]
    • Anterior [Towards the front, or ventral surface, of the body site.]
    • Posterior [Towards the back, or dorsal surface, of the body site.]
    • Proximal [More central or closer to the point of attachment, and usually describing part of a limb, digit or appendage.]
    • Distal [More peripheral, or further from the point of attachment, and usually describing part of a limb, digit or appendage.]
    • Deep [Away from the surface of the body site.]
    • Superficial [Towards the surface of the body site.]
    • Palmar [Towards the palm of the hand.]
    • Plantar [Towards the sole of the foot.]
    • Dorsal [Towards the back of the hand or top of the foot. To be used as opposites of palmar or plantar, not as a synonym of posterior.]
    • Mid [In the middle of the body site.]
    • Oral [Towards the mouth. Usually used to describe locations within the digestive system.]
    • Anal [Towards the anus. Usually used to describe locations within the digestive system.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0055], code=at0055, itemType=ELEMENT, level=1, text=Anatomical Line, description=Additional detail using theoretical lines drawn through anatomical structures used to provide a consistent reference point on the human body., comment=Common anatomical lines have been included as a value set, which can be extended over time, plus a free text option. The additional use of this data element allows for recording of the typical position of the heart's apex beat at 5th intercostal space, left side, and mid-clavicular line. If the 'Body site name' data element uses pre-coordinated terms that include anatomical line, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Midline [Line running vertically which divides the body into left and right portions, passing through the head, spinal cord, and umbilicus. Alternatively it can refer to a line dividing a body part into two equal portions, for example a digit.]
    • Midaxillary line [Line running vertically down the surface of the body, passing through the apex of the axilla.]
    • Anterior axillary line [Line running vertically down the surface of the body, passing through the anterior axillary skinfold.]
    • Posterior axillary line [Line running vertically down the surface of the body, passing through the posterior axillary skinfold.]
    • Mid-clavicular line [Line running vertically down the surface of the body, parallel to the midline and passing through the midpoint of the clavicle.]
    • Mid-pupillary line [Line running vertically down the face through the midpoint of the pupil when looking directly forward.]
    • Mid-scapular line [Line running vertically down the posterior surface of the body, parallel to the midline and passing through the inferior point of the scapula.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=ELEMENT, level=1, text=Description, description=Narrative description that can be used to further refine and support the 'Body site name'., comment=For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area., 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[at0053], code=at0053, itemType=SLOT, level=1, text=Alternative structure, description=Additional detail about the anatomical site using alternative approaches to describe the same body site., comment=For example, relative location or precise locations using coordinates., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations Or
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  • Left [Left side of the body.]
    [SNOMED-CT::419161000] (Unilateral left (qualifier value))
  • Right [Right side of the body.]
    [SNOMED-CT::419465000] (Unilateral right (qualifier value))
  • Left and right [Both sides of the body.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0083], code=at0083, itemType=ELEMENT, level=1, text=Occurrence, description=One or more sides of the body., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Unilateral [One-sided.]
  • Bilateral [Two-sided.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0064], code=at0064, itemType=ELEMENT, level=1, text=Aspect, description=Qualifying detail about the specific aspect of the identified body site., comment=Use to increase precision of identification of the body site, if required. Common aspects have been included as a value set, which can be extended over time, plus a free text option. Assumes that the body is being described while in the anatomical position. For example: proximal urethra; plantar aspect of the left thumb. Multiple aspects can also be described, if required, by allowing for 0..2 occurrences. For example: a lesion may be on the left anterior/lateral (ie anterolateral) chest wall. If the 'Body site name' data element uses pre-coordinated terms that include the aspect, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Medial [Towards the midline of the body site.]
    • Lateral [Towards the side, or edge, of the body site.]
    • Superior [Above the body site, often meaning towards the head.]
    • Inferior [Below the body site, often meaning towards the feet.]
    • Anterior [Towards the front, or ventral surface, of the body site.]
    • Posterior [Towards the back, or dorsal surface, of the body site.]
    • Proximal [More central or closer to the point of attachment, and usually describing part of a limb, digit or appendage.]
    • Distal [More peripheral, or further from the point of attachment, and usually describing part of a limb, digit or appendage.]
    • Deep [Away from the surface of the body site.]
    • Superficial [Towards the surface of the body site.]
    • Palmar [Towards the palm of the hand.]
    • Plantar [Towards the sole of the foot.]
    • Dorsal [Towards the back of the hand or top of the foot. To be used as opposites of palmar or plantar, not as a synonym of posterior.]
    • Mid [In the middle of the body site.]
    • Oral [Towards the mouth. Usually used to describe locations within the digestive system.]
    • Anal [Towards the anus. Usually used to describe locations within the digestive system.]
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0055], code=at0055, itemType=ELEMENT, level=1, text=Anatomical Line, description=Additional detail using theoretical lines drawn through anatomical structures used to provide a consistent reference point on the human body., comment=Common anatomical lines have been included as a value set, which can be extended over time, plus a free text option. The additional use of this data element allows for recording of the typical position of the heart's apex beat at 5th intercostal space, left side, and mid-clavicular line. If the 'Body site name' data element uses pre-coordinated terms that include anatomical line, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Coded Text
    • Midline [Line running vertically which divides the body into left and right portions, passing through the head, spinal cord, and umbilicus. Alternatively it can refer to a line dividing a body part into two equal portions, for example a digit.]
    • Midaxillary line [Line running vertically down the surface of the body, passing through the apex of the axilla.]
    • Anterior axillary line [Line running vertically down the surface of the body, passing through the anterior axillary skinfold.]
    • Posterior axillary line [Line running vertically down the surface of the body, passing through the posterior axillary skinfold.]
    • Mid-clavicular line [Line running vertically down the surface of the body, parallel to the midline and passing through the midpoint of the clavicle.]
    • Mid-pupillary line [Line running vertically down the face through the midpoint of the pupil when looking directly forward.]
    • Mid-scapular line [Line running vertically down the posterior surface of the body, parallel to the midline and passing through the inferior point of the scapula.]
  •  Text
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openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations Or
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openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]