| 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 | >
|
|---|
| 423 | ["at0.55"] = <
|
|---|
| 424 | description = <"The fetal sacrum is towards the sacrum">
|
|---|
| 425 | text = <"Sacro-Posterior">
|
|---|
| 426 | >
|
|---|
| 427 | ["at0.56"] = <
|
|---|
| 428 | description = <"The fetal sacrum is towards the left">
|
|---|
| 429 | text = <"Left Sacro-transverse">
|
|---|
| 430 | >
|
|---|
| 431 | ["at0.57"] = <
|
|---|
| 432 | description = <"The fetal sacrum is to the left and symphasis">
|
|---|
| 433 | text = <"Left Sacro-anterior">
|
|---|
| 434 | >
|
|---|
| 435 | ["at0.58"] = <
|
|---|
| 436 | description = <"The fetal sacrum is to the left and posterior">
|
|---|
| 437 | text = <"Left Sacro-posterior">
|
|---|
| 438 | >
|
|---|
| 439 | ["at0.59"] = <
|
|---|
| 440 | description = <"The fetal chin is towards the right">
|
|---|
| 441 | text = <"Right Mento-transverse">
|
|---|
| 442 | >
|
|---|
| 443 | ["at0.6"] = <
|
|---|
| 444 | description = <"The lie is perpendicular to the mother's spine">
|
|---|
| 445 | text = <"Transverse">
|
|---|
| 446 | >
|
|---|
| 447 | ["at0.60"] = <
|
|---|
| 448 | description = <"The fetal chin is towards the right and anterior">
|
|---|
| 449 | text = <"Right Mento-anterior">
|
|---|
| 450 | >
|
|---|
| 451 | ["at0.61"] = <
|
|---|
| 452 | description = <"The fetal chin is to the right and posterior">
|
|---|
| 453 | text = <"Right Mento-posterior">
|
|---|
| 454 | >
|
|---|
| 455 | ["at0.62"] = <
|
|---|
| 456 | description = <"The fetal chin is towards the symphasis">
|
|---|
| 457 | text = <"Mento-Anterior">
|
|---|
| 458 | >
|
|---|
| 459 | ["at0.63"] = <
|
|---|
| 460 | description = <"The fetal chin is towards the sacrum">
|
|---|
| 461 | text = <"Mento-Posterior">
|
|---|
| 462 | >
|
|---|
| 463 | ["at0.64"] = <
|
|---|
| 464 | description = <"The fetal chin is towards the left">
|
|---|
| 465 | text = <"Left Mento-transverse">
|
|---|
| 466 | >
|
|---|
| 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 | >
|
|---|
