archetype (adl_version=1.4) openEHR-EHR-CLUSTER.exam-uterine_cervix.v1 specialize openEHR-EHR-CLUSTER.exam.v1 concept [at0000.1] -- Examination of the cervix language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"unknown"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"A cluster for recording findings regarding the uterine cervix on physical examination."> use = <""> keywords = <"examination", "physical", "cervix", "uterine"> misuse = <""> > > lifecycle_state = <"Initial"> other_contributors = <> definition CLUSTER[at0000.1] matches { -- Examination of the cervix items cardinality matches {0..*; unordered} matches { CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements items cardinality matches {0..*; unordered} matches { ELEMENT[at0005] occurrences matches {0..*} matches { -- Normal statement value matches { DV_TEXT matches {*} } } } } ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } CLUSTER[at0008] occurrences matches {0..1} matches { -- Findings items cardinality matches {0..*; unordered} matches { ELEMENT[at0.8] occurrences matches {0..1} matches { -- Position value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.9, -- Central at0.10, -- To the right at0.11, -- To the left at0.12, -- Anterior at0.13] -- Posterior } } } } ELEMENT[at0.36] occurrences matches {0..1} matches { -- Consistency value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.37, -- Soft at0.38] -- Firm } } } } CLUSTER[at0007] occurrences matches {0..1} matches { -- Size items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/dimensions\.v1/} } } } CLUSTER[at0.48] occurrences matches {0..1} matches { -- Labour-specific findings items cardinality matches {0..*; unordered} matches { ELEMENT[at0.14] occurrences matches {0..1} matches { -- Effacement value matches { 0|[local::at0.15], -- Uneffaced 5|[local::at0.26], -- Ripe 10|[local::at0.16], -- 10% effaced 20|[local::at0.17], -- 20% effaced 30|[local::at0.18], -- 30% effaced 40|[local::at0.19], -- 40% effaced 50|[local::at0.20], -- Partially (50%) effaced 60|[local::at0.21], -- 60% effaced 70|[local::at0.22], -- 70% effaced 80|[local::at0.23], -- 80% effaced 90|[local::at0.24], -- 90% effaced 100|[local::at0.25] -- Fully effaced } } ELEMENT[at0.40] occurrences matches {0..1} matches { -- Thickness value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.41, -- Thick at0.42, -- Thin at0.43, -- Paper-thin at0.44] -- Oedematous } } } } ELEMENT[at0.45] occurrences matches {0..1} matches { -- Application to presenting part value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.46, -- Loosely applied at0.47] -- Tightly applied } } } } CLUSTER[at0.27] occurrences matches {0..2} matches { -- Cervical os items cardinality matches {0..*; unordered} matches { ELEMENT[at0.32] occurrences matches {0..1} matches { -- Site value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.33, -- External os at0.34] -- Internal os } } } } CLUSTER[at0.31] occurrences matches {0..1} matches { -- Dilation items cardinality matches {0..*; unordered} matches { ELEMENT[at0.28] occurrences matches {0..1} matches { -- Estimate value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"cm"> magnitude = <|0.0..10.0|> precision = <|1|> > > > } } ELEMENT[at0.35] occurrences matches {0..1} matches { -- Number of finger tips admitted value matches { DV_COUNT matches {*} } } } } ELEMENT[at0.29] occurrences matches {0..1} matches { -- Findings value matches { DV_TEXT matches {*} } } } } } } allow_archetype CLUSTER occurrences matches {0..*} matches { include archetype_id/value matches {/palpation\.v1draft/} archetype_id/value matches {/inspection\.v1draft/} exclude archetype_id/value matches {/.*/} } CLUSTER[at0.30] occurrences matches {0..1} matches { -- Vaginal fluid items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/fluid\.v1/} } } } CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/exam\.v1/} archetype_id/value matches {/exam-fetus\.v1/} } } } } } ELEMENT[at0006] occurrences matches {0..*} matches { -- Image value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 426, 427, 429] } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0.1"] = < description = <"Information about the size of the object for examination"> text = <"Size"> > ["at0.10"] = < description = <"The cervix is deviated to the right"> text = <"To the right"> > ["at0.11"] = < description = <"The cervix is deviated to the left"> text = <"To the left"> > ["at0.12"] = < description = <"The cervix is anterior near the pubis"> text = <"Anterior"> > ["at0.13"] = < description = <"The cervix is at the back near the sacrum"> text = <"Posterior"> > ["at0.14"] = < description = <"The effacement of the uterine cervix in late pregnancy or labour."> text = <"Effacement"> > ["at0.15"] = < description = <"The cervix has not changed its form"> text = <"Uneffaced"> > ["at0.16"] = < description = <"The cervix is effaced to about 10%"> text = <"10% effaced"> > ["at0.17"] = < description = <"The cervix is effaced to about 20%"> text = <"20% effaced"> > ["at0.18"] = < description = <"The cervix is effaced to about 30%"> text = <"30% effaced"> > ["at0.19"] = < description = <"The cervix is effaced to about 40%"> text = <"40% effaced"> > ["at0.20"] = < description = <"The cervix is partially effaced to about 50%"> text = <"Partially (50%) effaced"> > ["at0.21"] = < description = <"The cervix is effaced to about 60%"> text = <"60% effaced"> > ["at0.22"] = < description = <"The cervix is effaced to about 70%"> text = <"70% effaced"> > ["at0.23"] = < description = <"The cervix is effaced to about 80%"> text = <"80% effaced"> > ["at0.24"] = < description = <"The cervix is effaced to about 90%"> text = <"90% effaced"> > ["at0.25"] = < description = <"The cervix is fully effaced to 100%"> text = <"Fully effaced"> > ["at0.26"] = < description = <"The cervix is ripe and beginning to efface"> text = <"Ripe"> > ["at0.27"] = < description = <"The outlet of the uterus"> text = <"Cervical os"> > ["at0.28"] = < description = <"The dilation of the os"> text = <"Estimate"> > ["at0.29"] = < description = <"Findings about the cervical os"> text = <"Findings"> > ["at0.30"] = < description = <"Vaginal loss or discharge"> text = <"Vaginal fluid"> > ["at0.31"] = < description = <"Dilation of cervix"> text = <"Dilation"> > ["at0.32"] = < description = <"Identify part of cervix which is being examined"> text = <"Site"> > ["at0.33"] = < description = <"External opening of the cervix to the vagina"> text = <"External os"> > ["at0.34"] = < description = <"Internal opening of the cervix to the uterus"> text = <"Internal os"> > ["at0.35"] = < description = <"Number of finger tips that are able to be admitted into the internal or external os"> text = <"Number of finger tips admitted"> > ["at0.36"] = < description = <"Consistency of cervix"> text = <"Consistency"> > ["at0.37"] = < description = <"Soft"> text = <"Soft"> > ["at0.38"] = < description = <"Firm"> text = <"Firm"> > ["at0.39"] = < description = <"Length of cervix"> text = <"Length"> > ["at0.40"] = < description = <"Cervical thickness"> text = <"Thickness"> > ["at0.41"] = < description = <"Thick"> text = <"Thick"> > ["at0.42"] = < description = <"Thin"> text = <"Thin"> > ["at0.43"] = < description = <"Very thin"> text = <"Paper-thin"> > ["at0.44"] = < description = <"Thickened and swollen"> text = <"Oedematous"> > ["at0.45"] = < description = <"Application of cervix to fetal presenting part"> text = <"Application to presenting part"> > ["at0.46"] = < description = <"Not moulded to presenting part"> text = <"Loosely applied"> > ["at0.47"] = < description = <"Moulded to presenting part"> text = <"Tightly applied"> > ["at0.48"] = < description = <"*"> text = <"Labour-specific findings"> > ["at0.8"] = < description = <"The position in relation to the normal anatomical position"> text = <"Position"> > ["at0.9"] = < description = <"The cervix is central and in the normal position"> text = <"Central"> > ["at0000"] = < description = <"Generic examination cluster for describing a finding on physical examination"> text = <"Examination"> > ["at0000.1"] = < description = <"Examination findings on physical examination of the uterine cervix"> text = <"Examination of the cervix"> > ["at0001"] = < description = <"The object of the examination"> text = <"Object"> > ["at0002"] = < description = <"Textural description of the part examined"> text = <"Clinical description"> > ["at0003"] = < description = <"More focused examination findings"> text = <"Detail"> > ["at0004"] = < description = <"A group of statements about the normality of the examination"> text = <"Normal statements"> > ["at0005"] = < description = <"A specific statement of normality"> text = <"Normal statement"> > ["at0006"] = < description = <"Drawing or image of the area examined"> text = <"Image"> > ["at0007"] = < description = <"Information about the size of the object for examination"> text = <"Size"> > ["at0008"] = < description = <"Clinical findings"> text = <"Findings"> > > > >