1 | archetype (adl_version=1.4)
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2 | openEHR-EHR-CLUSTER.exam-fetus.v1
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3 | specialize
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4 | openEHR-EHR-CLUSTER.exam.v1
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5 |
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6 | concept
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7 | [at0000.1] -- Examination of the fetus
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8 | language
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9 | original_language = <[ISO_639-1::en]>
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10 | description
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11 | original_author = <
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12 | ["name"] = <"unknown">
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13 | >
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14 | details = <
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15 | ["en"] = <
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16 | language = <[ISO_639-1::en]>
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17 | purpose = <"For recording findings on physical examination relating to the fetus while in the uterus">
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18 | use = <"">
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19 | keywords = <"foetus", "fetal", "foetal">
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20 | misuse = <"">
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21 | >
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22 | >
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23 | lifecycle_state = <"Initial">
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24 | other_contributors = <>
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25 |
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26 | definition
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27 | CLUSTER[at0000.1] matches { -- Examination of the fetus
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28 | items cardinality matches {0..*; unordered} matches {
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29 | CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements
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30 | items cardinality matches {0..*; unordered} matches {
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31 | ELEMENT[at0005] occurrences matches {0..*} matches { -- Normal statement
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32 | value matches {
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33 | DV_TEXT matches {*}
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34 | }
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35 | }
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36 | }
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37 | }
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38 | ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description
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39 | value matches {
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40 | DV_TEXT matches {*}
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41 | }
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42 | }
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43 | CLUSTER[at0008] occurrences matches {0..1} matches { -- Findings
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44 | items cardinality matches {0..*; unordered} matches {
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45 | ELEMENT[at0.4] occurrences matches {0..1} matches { -- Lie of the fetus
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46 | value matches {
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47 | DV_CODED_TEXT matches {
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48 | defining_code matches {
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49 | [local::
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50 | at0.5, -- Longitudinal
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51 | at0.6, -- Transverse
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52 | at0.7] -- Oblique
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53 | }
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54 | }
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55 | }
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56 | }
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57 | ELEMENT[at0.8] occurrences matches {0..1} matches { -- Presentation
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58 | value matches {
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59 | DV_CODED_TEXT matches {
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60 | defining_code matches {
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61 | [local::
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62 | at0.9, -- Cephalic
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63 | at0.10, -- Breech
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64 | at0.11, -- Full breech
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65 | at0.12, -- Extended breech
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66 | at0.13, -- Shoulder
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67 | at0.69, -- Footling breech
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68 | at0.70, -- Face
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69 | at0.71, -- Cord
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70 | at0.72] -- Compound
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71 | }
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72 | }
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73 | }
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74 | }
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75 | ELEMENT[at0.42] occurrences matches {0..1} matches { -- Position
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76 | value matches {
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77 | DV_CODED_TEXT matches {
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78 | defining_code matches {
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79 | [local::
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80 | at0.43, -- Right Occipito-transverse
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81 | at0.44, -- Right Occipito-anterior
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82 | at0.45, -- Right Occipito-posterior
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83 | at0.46, -- Occipito-anterior
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84 | at0.47, -- Occipito-posterior
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85 | at0.48, -- Left Occipito-transverse
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86 | at0.49, -- Left Occipito-anterior
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87 | at0.50, -- Left Occipito-posterior
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88 | at0.51, -- Right Sacro-transverse
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89 | at0.52, -- Right Sacro-anterior
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90 | at0.53, -- Right Sacro-posterior
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91 | at0.54, -- Sacro-Anterior
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92 | at0.55, -- Sacro-Posterior
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93 | at0.56, -- Left Sacro-transverse
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94 | at0.57, -- Left Sacro-anterior
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95 | at0.58, -- Left Sacro-posterior
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96 | at0.59, -- Right Mento-transverse
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97 | at0.60, -- Right Mento-anterior
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98 | at0.61, -- Right Mento-posterior
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99 | at0.62, -- Mento-Anterior
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100 | at0.63, -- Mento-Posterior
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101 | at0.64, -- Left Mento-transverse
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102 | at0.65, -- Left Mento-anterior
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103 | at0.61] -- Right Mento-posterior
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104 | }
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105 | }
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106 | }
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107 | }
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108 | ELEMENT[at0.32] occurrences matches {0..1} matches { -- Attitude
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109 | value matches {
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110 | DV_CODED_TEXT matches {
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111 | defining_code matches {
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112 | [local::
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113 | at0.33, -- Flexed
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114 | at0.34, -- Deflexed
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115 | at0.35] -- Extended
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116 | }
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117 | }
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118 | }
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119 | }
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120 | CLUSTER[at0.74] occurrences matches {0..1} matches { -- Engagement
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121 | items cardinality matches {0..*; unordered} matches {
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122 | ELEMENT[at0.22] occurrences matches {0..1} matches { -- Fifths
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123 | value matches {
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124 | DV_CODED_TEXT matches {
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125 | defining_code matches {
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126 | [local::
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127 | at0.23, -- Not engaged (0/5)
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128 | at0.24, -- 1/5
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129 | at0.25, -- 2/5
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130 | at0.26, -- 3/5
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131 | at0.27, -- 4/5
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132 | at0.28] -- Fully engaged (5/5)
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133 | }
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134 | }
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135 | }
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136 | }
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137 | ELEMENT[at0.75] occurrences matches {0..1} matches { -- Qualitative
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138 | value matches {
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139 | DV_CODED_TEXT matches {
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140 | defining_code matches {
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141 | [local::
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142 | at0.76, -- High and mobile
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143 | at0.77, -- At pelvic brim
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144 | at0.78] -- Engaged
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145 | }
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146 | }
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147 | }
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148 | }
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149 | }
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150 | }
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151 | ELEMENT[at0.14] occurrences matches {0..1} matches { -- Size relative to gestation
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152 | value matches {
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153 | DV_CODED_TEXT matches {
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154 | defining_code matches {
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155 | [local::
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156 | at0.15, -- Small for dates
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157 | at0.67, -- ? small for dates
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158 | at0.16, -- Normal
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159 | at0.68, -- ? large for dates
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160 | at0.17] -- Large for dates
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161 | }
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162 | }
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163 | }
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164 | }
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165 | ELEMENT[at0.29] occurrences matches {0..1} matches { -- Station
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166 | value matches {
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167 | C_DV_QUANTITY <
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168 | property = <[openehr::122]>
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169 | list = <
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170 | ["1"] = <
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171 | units = <"cm">
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172 | magnitude = <|-5.0..5.0|>
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173 | precision = <|0|>
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174 | >
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175 | >
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176 | >
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177 | }
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178 | }
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179 | ELEMENT[at0.18] occurrences matches {0..1} matches { -- Estimated fetal weight
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180 | value matches {
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181 | C_DV_QUANTITY <
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182 | property = <[openehr::124]>
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183 | list = <
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184 | ["1"] = <
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185 | units = <"kg">
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186 | magnitude = <|0.0..20.0|>
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187 | >
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188 | ["2"] = <
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189 | units = <"gm">
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190 | magnitude = <|0.0..20000.0|>
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191 | precision = <|0|>
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192 | >
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193 | >
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194 | >
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195 | }
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196 | }
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197 | CLUSTER[at0007] occurrences matches {0..1} matches { -- Size
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198 | items cardinality matches {0..*; unordered} matches {
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199 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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200 | include
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201 | archetype_id/value matches {/dimensions\.v1/}
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202 | archetype_id/value matches {/size\.v1draft/}
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203 | }
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204 | }
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205 | }
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206 | CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail
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207 | items cardinality matches {0..*; unordered} matches {
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208 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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209 | include
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210 | archetype_id/value matches {/exam\.v1/}
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211 | }
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212 | }
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213 | }
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214 | }
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215 | }
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216 | ELEMENT[at0006] occurrences matches {0..*} matches { -- Image
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217 | value matches {
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218 | DV_MULTIMEDIA matches {
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219 | media_type matches {
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220 | [openEHR::
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221 | 426,
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222 | 427,
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223 | 429]
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224 | }
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225 | }
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226 | }
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227 | }
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228 | }
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229 | }
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230 |
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231 | ontology
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232 | term_definitions = <
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233 | ["en"] = <
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234 | items = <
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235 | ["at0.10"] = <
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236 | description = <"The breech is the presenting part">
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237 | text = <"Breech">
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238 | >
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239 | ["at0.11"] = <
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240 | description = <"The breech is presenting with the legs flexed">
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241 | text = <"Full breech">
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242 | >
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243 | ["at0.12"] = <
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244 | description = <"The breech is the presenting part with the leg(s) extended">
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245 | text = <"Extended breech">
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246 | >
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247 | ["at0.13"] = <
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248 | description = <"The shoulder is the presenting part">
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249 | text = <"Shoulder">
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250 | >
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251 | ["at0.14"] = <
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252 | description = <"The apparent size of the baby relative to normal for gestation">
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253 | text = <"Size relative to gestation">
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254 | >
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255 | ["at0.15"] = <
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256 | description = <"The size of the baby is smaller than expected for gestation">
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257 | text = <"Small for dates">
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258 | >
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259 | ["at0.16"] = <
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260 | description = <"The size of the baby is normal for gestation">
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261 | text = <"Normal">
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262 | >
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263 | ["at0.17"] = <
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264 | description = <"The size of the baby is larger than expected for gestation">
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265 | text = <"Large for dates">
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266 | >
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267 | ["at0.18"] = <
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268 | description = <"The estimated weight of the baby on examination">
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269 | text = <"Estimated fetal weight">
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270 | >
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271 | ["at0.19"] = <
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272 | description = <"The position of the head in relation to the pelvis">
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273 | text = <"Denominator">
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274 | >
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275 | ["at0.20"] = <
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276 | description = <"The occiput is anterior rotated to the anterior">
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277 | text = <"Left occipito-anterior">
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278 | >
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279 | ["at0.21"] = <
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280 | description = <"The occiput is at the back">
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281 | text = <"Occipito-posterior">
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282 | >
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283 | ["at0.22"] = <
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284 | description = <"The proportion of the presenting part which is felt above the pelvis">
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285 | text = <"Fifths">
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286 | >
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287 | ["at0.23"] = <
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288 | description = <"The head is not engaged in the pelvis">
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289 | text = <"Not engaged (0/5)">
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290 | >
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291 | ["at0.24"] = <
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292 | description = <"About 20% of the head is inside the pelvis">
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293 | text = <"1/5">
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294 | >
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295 | ["at0.25"] = <
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296 | description = <"About 40% of the head is inside the pelvis">
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297 | text = <"2/5">
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298 | >
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299 | ["at0.26"] = <
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300 | description = <"About 60% of the head is inside the pelvis">
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301 | text = <"3/5">
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302 | >
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303 | ["at0.27"] = <
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304 | description = <"About 80% of the head is inside the pelvis">
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305 | text = <"4/5">
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306 | >
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307 | ["at0.28"] = <
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308 | description = <"The head is inside the pelvis">
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309 | text = <"Fully engaged (5/5)">
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310 | >
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311 | ["at0.29"] = <
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312 | description = <"Posiiton relative to the ischial spines (minus is above, 0 is at the spines and plus is below)">
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313 | text = <"Station">
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314 | >
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315 | ["at0.30"] = <
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316 | description = <"The occiput is adjacent to the symphasis pubis">
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317 | text = <"Occipito-anterior">
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318 | >
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319 | ["at0.31"] = <
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320 | description = <"The occiput is anterior rotated to the right">
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321 | text = <"Right occipito-anterior">
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322 | >
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323 | ["at0.32"] = <
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324 | description = <"The degree of flexion of the body">
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325 | text = <"Attitude">
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326 | >
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327 | ["at0.33"] = <
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328 | description = <"The fetus is fully flexed">
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329 | text = <"Flexed">
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330 | >
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331 | ["at0.34"] = <
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332 | description = <"The fetus is not flexed">
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333 | text = <"Deflexed">
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334 | >
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335 | ["at0.35"] = <
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336 | description = <"The fetus is extended">
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337 | text = <"Extended">
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338 | >
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339 | ["at0.36"] = <
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340 | description = <"The occiput is on the left">
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341 | text = <"Left occipito-transverse">
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342 | >
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343 | ["at0.37"] = <
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344 | description = <"The occiput is on the right">
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345 | text = <"Right occipito-transverse">
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346 | >
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347 | ["at0.38"] = <
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348 | description = <"*">
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349 | text = <"Position">
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350 | >
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351 | ["at0.39"] = <
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352 | description = <"The occipital bone">
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353 | text = <"Occipito">
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354 | >
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355 | ["at0.4"] = <
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356 | description = <"The position of the fetus">
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357 | text = <"Lie of the fetus">
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358 | >
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359 | ["at0.40"] = <
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360 | description = <"The chin">
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361 | text = <"Mento">
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362 | >
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363 | ["at0.41"] = <
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364 | description = <"The sacral bone">
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365 | text = <"Sacro">
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366 | >
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367 | ["at0.42"] = <
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368 | description = <"The orientation of the denominator">
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369 | text = <"Position">
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370 | >
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371 | ["at0.43"] = <
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372 | description = <"The occiput is towards the right">
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373 | text = <"Right Occipito-transverse">
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374 | >
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375 | ["at0.44"] = <
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376 | description = <"The occiput is towards the right and anterior">
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377 | text = <"Right Occipito-anterior">
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378 | >
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379 | ["at0.45"] = <
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380 | description = <"The occiput is to the right and posterior">
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381 | text = <"Right Occipito-posterior">
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382 | >
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383 | ["at0.46"] = <
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384 | description = <"The occiput is towards the symphasis">
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385 | text = <"Occipito-anterior">
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386 | >
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387 | ["at0.47"] = <
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388 | description = <"The occiput is towards the sacrum">
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389 | text = <"Occipito-posterior">
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390 | >
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391 | ["at0.48"] = <
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392 | description = <"The occiput is towards the left">
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393 | text = <"Left Occipito-transverse">
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394 | >
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395 | ["at0.49"] = <
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396 | description = <"The occiput is to the left and symphasis">
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397 | text = <"Left Occipito-anterior">
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398 | >
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399 | ["at0.5"] = <
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400 | description = <"The lie is along the line of the mother's spine">
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401 | text = <"Longitudinal">
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402 | >
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403 | ["at0.50"] = <
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404 | description = <"The occiput is to the left and posterior">
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405 | text = <"Left Occipito-posterior">
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406 | >
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407 | ["at0.51"] = <
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408 | description = <"The fetal sacrum is towards the right">
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409 | text = <"Right Sacro-transverse">
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410 | >
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411 | ["at0.52"] = <
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412 | description = <"The fetal sacrum is towards the right and anterior">
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413 | text = <"Right Sacro-anterior">
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414 | >
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415 | ["at0.53"] = <
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416 | description = <"The fetal sacrum is to the right and posterior">
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417 | text = <"Right Sacro-posterior">
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418 | >
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419 | ["at0.54"] = <
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420 | description = <"The fetal sacrum is towards the symphasis">
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421 | text = <"Sacro-Anterior">
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422 | >
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423 | ["at0.55"] = <
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424 | description = <"The fetal sacrum is towards the sacrum">
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425 | text = <"Sacro-Posterior">
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426 | >
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427 | ["at0.56"] = <
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428 | description = <"The fetal sacrum is towards the left">
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429 | text = <"Left Sacro-transverse">
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430 | >
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431 | ["at0.57"] = <
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432 | description = <"The fetal sacrum is to the left and symphasis">
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433 | text = <"Left Sacro-anterior">
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434 | >
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435 | ["at0.58"] = <
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436 | description = <"The fetal sacrum is to the left and posterior">
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437 | text = <"Left Sacro-posterior">
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438 | >
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439 | ["at0.59"] = <
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440 | description = <"The fetal chin is towards the right">
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441 | text = <"Right Mento-transverse">
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442 | >
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443 | ["at0.6"] = <
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444 | description = <"The lie is perpendicular to the mother's spine">
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445 | text = <"Transverse">
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446 | >
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447 | ["at0.60"] = <
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448 | description = <"The fetal chin is towards the right and anterior">
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449 | text = <"Right Mento-anterior">
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450 | >
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451 | ["at0.61"] = <
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452 | description = <"The fetal chin is to the right and posterior">
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453 | text = <"Right Mento-posterior">
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454 | >
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455 | ["at0.62"] = <
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456 | description = <"The fetal chin is towards the symphasis">
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457 | text = <"Mento-Anterior">
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458 | >
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459 | ["at0.63"] = <
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460 | description = <"The fetal chin is towards the sacrum">
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461 | text = <"Mento-Posterior">
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462 | >
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463 | ["at0.64"] = <
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464 | description = <"The fetal chin is towards the left">
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465 | text = <"Left Mento-transverse">
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466 | >
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467 | ["at0.65"] = <
|
---|
468 | description = <"The fetal chin is to the left and symphasis">
|
---|
469 | text = <"Left Mento-anterior">
|
---|
470 | >
|
---|
471 | ["at0.66"] = <
|
---|
472 | description = <"The fetal chin is to the left and posterior">
|
---|
473 | text = <"Left Mento-posterior">
|
---|
474 | >
|
---|
475 | ["at0.67"] = <
|
---|
476 | description = <"Possibly small for this gestation">
|
---|
477 | text = <"? small for dates">
|
---|
478 | >
|
---|
479 | ["at0.68"] = <
|
---|
480 | description = <"Possibly larger than expected for this gestation">
|
---|
481 | text = <"? large for dates">
|
---|
482 | >
|
---|
483 | ["at0.69"] = <
|
---|
484 | description = <"A fetal foot is extended and presenting">
|
---|
485 | text = <"Footling breech">
|
---|
486 | >
|
---|
487 | ["at0.7"] = <
|
---|
488 | description = <"The lie is oblique to the mother's spine">
|
---|
489 | text = <"Oblique">
|
---|
490 | >
|
---|
491 | ["at0.70"] = <
|
---|
492 | description = <"The head is extended and the face is presenting">
|
---|
493 | text = <"Face">
|
---|
494 | >
|
---|
495 | ["at0.71"] = <
|
---|
496 | description = <"The umbilical cord is presenting">
|
---|
497 | text = <"Cord">
|
---|
498 | >
|
---|
499 | ["at0.72"] = <
|
---|
500 | description = <"There is a compound presentation">
|
---|
501 | text = <"Compound">
|
---|
502 | >
|
---|
503 | ["at0.73"] = <
|
---|
504 | description = <"*">
|
---|
505 | text = <"Station">
|
---|
506 | >
|
---|
507 | ["at0.74"] = <
|
---|
508 | description = <"Estimation of presenting part in relation to pelvic brim">
|
---|
509 | text = <"Engagement">
|
---|
510 | >
|
---|
511 | ["at0.75"] = <
|
---|
512 | description = <"Description of engagement of fetal head">
|
---|
513 | text = <"Qualitative">
|
---|
514 | >
|
---|
515 | ["at0.76"] = <
|
---|
516 | description = <"*">
|
---|
517 | text = <"High and mobile">
|
---|
518 | >
|
---|
519 | ["at0.77"] = <
|
---|
520 | description = <"*">
|
---|
521 | text = <"At pelvic brim">
|
---|
522 | >
|
---|
523 | ["at0.78"] = <
|
---|
524 | description = <"*">
|
---|
525 | text = <"Engaged">
|
---|
526 | >
|
---|
527 | ["at0.79"] = <
|
---|
528 | description = <"*">
|
---|
529 | text = <"Estimation">
|
---|
530 | >
|
---|
531 | ["at0.8"] = <
|
---|
532 | description = <"The presenting part of the fetus">
|
---|
533 | text = <"Presentation">
|
---|
534 | >
|
---|
535 | ["at0.9"] = <
|
---|
536 | description = <"The head is the presenting part">
|
---|
537 | text = <"Cephalic">
|
---|
538 | >
|
---|
539 | ["at0000"] = <
|
---|
540 | description = <"Generic examination cluster for describing a finding on physical examination">
|
---|
541 | text = <"Examination">
|
---|
542 | >
|
---|
543 | ["at0000.1"] = <
|
---|
544 | description = <"Examination cluster for describing a finding on physical examination of a fetus">
|
---|
545 | text = <"Examination of the fetus">
|
---|
546 | >
|
---|
547 | ["at0002"] = <
|
---|
548 | description = <"Textural description of the part examined">
|
---|
549 | text = <"Clinical description">
|
---|
550 | >
|
---|
551 | ["at0003"] = <
|
---|
552 | description = <"More focused examination findings">
|
---|
553 | text = <"Detail">
|
---|
554 | >
|
---|
555 | ["at0004"] = <
|
---|
556 | description = <"A group of statements about the normality of the examination">
|
---|
557 | text = <"Normal statements">
|
---|
558 | >
|
---|
559 | ["at0005"] = <
|
---|
560 | description = <"A specific statement of normality">
|
---|
561 | text = <"Normal statement">
|
---|
562 | >
|
---|
563 | ["at0006"] = <
|
---|
564 | description = <"Drawing or image of the area examined">
|
---|
565 | text = <"Image">
|
---|
566 | >
|
---|
567 | ["at0007"] = <
|
---|
568 | description = <"Information about the size of the object for examination">
|
---|
569 | text = <"Size">
|
---|
570 | >
|
---|
571 | ["at0008"] = <
|
---|
572 | description = <"Clinical findings">
|
---|
573 | text = <"Findings">
|
---|
574 | >
|
---|
575 | >
|
---|
576 | >
|
---|
577 | >
|
---|