- 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: 879bf80355e0b5633622772a3f01b0f3
- PARENT:MD5-CAM-1.0.1: 005501C1FA493A4838F5F1121F2870EC
- Build Uid: 5b4193bc-2b9b-43fb-9506-42f061ab3728
- Original Language: ISO_639-1::en
- Sem Ver: 49.0.0
- 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.
- HCC Examination
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
- Liver
- 0
- 1
- 2
- 3
- >3
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
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.
- Liver segment 1
- Liver segment 2
- Liver segment 3
- Liver segment 4
- Liver segment 4a
- Liver segment 4b
- Liver segment 5
- Liver segment 6
- Liver segment 7
- Liver segment 8
- CT/MRI Diagnostic LI-RADS
- LR-NC
- LR-TIV
- LR-1
- LR-2
- LR-3
- LR-4
- LR-5
- LR-M
- LR-TR Not assessable
- LR-TR nonviable
- LR-TR not clear
- LR-TR vital
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
- Yes
- No
- Unclear
This data element has unlimited occurrences to allow for measurements in 2 or more axes. If there is no clear orientation of the anomaly, for example length vs width vs height, use multiple occurrences to allow recording of the length of 2 or more axes without any specific orientation, for example 3 x 4 x 5 mm.
>=0; >=0
Units:
- mm
- cm
This data element has unlimited occurrences to allow for measurements in 2 or more axes. If there is no clear orientation of the anomaly, for example length vs width vs height, use multiple occurrences to allow recording of the length of 2 or more axes without any specific orientation, for example 3 x 4 x 5 mm.
>=0; >=0
Units:
- mm
- cm
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.
- 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.
- 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
- Bone
- Liver
- Brain
- Lymph node
- Bone marrow
- Pleura
- Peritoneum
- Adrenal gland
- Kidney
- Skin
- Other organs
- Generalized metastasis
- 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).
- PR (partial response)
- SD (stable disease)
- PD (progressive disease)
- CR (complete response)
- U (assesment 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.
- Consistency of findings
- Improvement of findings
- Deterioration of findings
- Divergent behavior
- Assessment is not possible
- Not applicable (initial findings)
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'.
- Sufficient quality
- Quality limited
- Non-diagnostic
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
- Portal Venous Phase - Yes
- Portal 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 - Ja
- T2 axial - Nein
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 CM
- Liver-specific CM
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.