- 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
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: 330ca5e71d78e5df32fea7480c79978d
- PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC
- Build Uid: 0c80c276-ecf5-4634-8c81-20008f20ecd3
- Original Language: ISO_639-1::en
- Sem Ver: 34.0.0
- Vorläufig
- Final
- Korrigiert
For example: 'CT abdomen'; 'Doppler ultrasound of renal artery' or 'Plain chest xray'. Coding with a terminology is strongly recommended, preferably a term specifying both modality and anatomical location, where possible. Examples of candidate terminologies are the LOINC Imaging Document Codes, RadLex Playbook or SNOMED-CT. Equivalent to DiagnosticReport.code in FHIR.
- Examination of the bile ducts
For example: 'XRay', 'CT scan', 'ultrasound', 'MRI', 'bone densitometry', 'tomography', 'mammography', 'nuclear medicine', 'PET', 'angiography', and 'fluoroscopy'. This data element may be redundant if the modality is clearly represented in the 'Study name'. Alternatively it may also be possible to autopopulate the 'Modality' from a coded 'Study name'. Coding of the 'Modality' with a value set is recommended, such as the DICOM CID 29 Acquisition Modality value set. Equivalent to ImagingStudy.modality in FHIR and Modality (0008, 0060) in DICOM.
- CT
- MR
Equivalent to ImagingStudy.started in FHIR.
Also known as 'Clinical question' or 'Clinical query'.
- Initial finding
- After neoadjuvant therapy
- After local therapy
- Under systemic therapy
- Follow-up without therapy
For example: a cyst or mass; a thrombosis; a polyp; a calculus or a foreign body.
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.
- Anomaly
- Ja
- Nein
- Unklar
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.
- Intrahepatic
- perihilar
- distal
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.
- Liver segment 1
- Liver segment 2
- Liver segment 3
- Liver segment 4
- Liver segment 4a
- Liver segment 4b
- Liver segment 4a/b
- Liver segment 5
- Liver segment 6
- Liver segment 7
- Liver segment 8
- Liver segments 2/3
- Liver segments 7/6
- Liver segments 8/5
- Liver segments 2/4a
- Liver segments 3/4b
- Not applicable
For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area.
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.
- Examination of the bile ducts
Terminology: local_terms
- No contact
- Contact ≤ 180°
- Contact > 180°
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.
- Vascular contact HA (hepatic artery)
Terminology: local_terms
- No contact
- Contact ≤ 180°
- Contact > 180°
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.
- Vascular contact AMS (Arteria mesenterica superior)
Terminology: local_terms
- No contact
- Contact ≤ 180°
- Contact > 180°
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.
- Vascular contact VMS (Vena mesenterica superia)
Terminology: local_terms
- No contact
- Contact ≤ 180°
- Contact > 180°
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.
- Vascular contact PA (incl. PA thrombosis)
Terminology: local_terms
- No contact
- Contact ≤ 180°
- Contact > 180°
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.
- Portal vein thrombosis
- Yes
- No
- Unclear
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.
- Distant metastases
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.
Terminology: local_terms
- Lung (PUL)
- Bone (OSS)
- Liver (HEP)
- Brain (BRA)
- Lymph nodes (LYM)
- Bone marrow (MAR)
- Pleura (PLE)
- Peritoneum (PER)
- Adrenal gland (ADR)
- Kidneys (KID)
- Skin (SKI)
- Other organs (OTH)
- Generalized metastasis (GEN)
- Yes
- No
- Unclear
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.
- Local recurrence
- Yes
- No
- Unclear
This is an already coded terminology of response to, for example, oncological therapy. Symptoms can be, for example, CR (complete remission of the disease), PR (partial remission), SD (stable disease) or PD (progression of the disease).
Terminology: local_terms
- PR (partial response)
- SD (stable disease)
- PD (progressive disease)
- CR (complete response)
- U (Assessment impossible)
- X (Missing information)
Also use this data element to indicate if no comparison images and/or reports are available. Details about the images used for comparison can be recorded using the 'Comparison study details' CLUSTER, within Protocol.
- Findings consistent
- Findings improvement
- Findings deterioration
- Divergent behavior
- Assessment not possible
- Not applicable (Initial finding)
Coding of the imaging quality with a value set is recommended. For example: 'excellent, good, fair, poor, and non-diagnostic'; or 'adequate, suboptimal and inadequate'.
- Qualität ausreichend
- Qualität eingeschränkt
- Nicht diagnostisch
Also referred to as 'Opinion' or 'Conclusion'. Equivalent to DiagnosticReport.conclusion in FHIR.
Equivalent to Study Instance UID (0020,000D) in DICOM and ImagingStudy.identifier in FHIR.
Identifier
Text
As one instance of this archetype is used per study, this identifier can be used to connect more than one imaging study within a single combined report. Equivalent to DiagnosticReport.identifier in FHIR.
- Identifier
- Text
e.g. B. Diffusion weighting in MRI, the type or route of contrast medium administration, radiopharmaceuticals and/or treatment applied.
- CT
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- Native Phase - Yes
- Native Phase - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- Late arterial phase - Yes
- Late Arterial Phase - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- Venous Phase - Yes
- Venous Phase - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- Late venous phase - Yes
- Late venous phase - No
e.g. B. Diffusion weighting in MRI, the type or route of contrast medium administration, radiopharmaceuticals and/or treatment applied.
- MR
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T1 with chemical Shift Imaging (in-opp-Phase /Dixon) axial - Yes
- T1 with chemical Shift Imaging (in-opp-Phase /Dixon) axial - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T1 GRE Fat Suppressed Native Axial - Yes
- T1 GRE Grease Suppressed Native Axial - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T1 GRE Fat Suppressed Late Arterial Axial - Yes
- T1 GRE Fat Suppressed Late Arterial Axial - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T1 GRE Fat Suppressed Venous Axial - Yes
- T1 GRE Fat Suppressed Venous Axial - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T1 GRE Fat Suppressed Late Venous Axial - Yes
- T1 GRE Fat Suppressed Late Venous Axial - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T1 GRE Fat Suppressed Hepatobiliary Axial - Yes
- T1 GRE Fat Suppressed Hepatobiliary Axial - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T2 axial - Yes
- T2 axial - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- T2 koronar - Ja
- T2 koronar - Nein
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- Diffusion-weighting b=0-100 s/mm2 - Yes
- Diffusion-weighting b=0-100 s/mm² - No
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- Diffusion weighting b=500-1000 s/mm² - Yes
- Diffusion weighting b=500-1000 s/mm² - No
e.g. B. Diffusion weighting in MRI, the type or route of contrast medium administration, radiopharmaceuticals and/or treatment applied.
- Contrast medium
e.g. B. Native phase, late arterial phase for CT, or T1 GRE fat suppressed late venous axial, T2 coronal for MRI
- Native
- Extracellular contrast medium
- Intracellular contrast medium
may contain a text comment such as "the patient refused the use of a contrast agent" or "MRI could not be performed due to...".
Intended to be used within the COMPOSITION.problem_list.
Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
For example: 'acute motor axonal neuropathy' as a variant of Guillain-Barre Syndrome. Coding of the name of the variant with a terminology is preferred, where possible.
Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.