1 | archetype (adl_version=1.4)
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2 | openEHR-EHR-CLUSTER.exam-uterine_cervix.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 cervix
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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 = <"A cluster for recording findings regarding the uterine cervix on physical examination.">
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18 | use = <"">
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19 | keywords = <"examination", "physical", "cervix", "uterine">
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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 cervix
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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[at0.8] occurrences matches {0..1} matches { -- Position
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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 | at0.9, -- Central
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51 | at0.10, -- To the right
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52 | at0.11, -- To the left
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53 | at0.12, -- Anterior
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54 | at0.13] -- Posterior
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55 | }
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56 | }
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57 | }
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58 | }
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59 | ELEMENT[at0.36] occurrences matches {0..1} matches { -- Consistency
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60 | value matches {
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61 | DV_CODED_TEXT matches {
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62 | defining_code matches {
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63 | [local::
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64 | at0.37, -- Soft
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65 | at0.38] -- Firm
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66 | }
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67 | }
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68 | }
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69 | }
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70 | CLUSTER[at0007] occurrences matches {0..1} matches { -- Size
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71 | items cardinality matches {0..*; unordered} matches {
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72 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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73 | include
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74 | archetype_id/value matches {/dimensions\.v1/}
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75 | }
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76 | }
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77 | }
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78 | CLUSTER[at0.48] occurrences matches {0..1} matches { -- Labour-specific findings
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79 | items cardinality matches {0..*; unordered} matches {
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80 | ELEMENT[at0.14] occurrences matches {0..1} matches { -- Effacement
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81 | value matches {
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82 | 0|[local::at0.15], -- Uneffaced
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83 | 5|[local::at0.26], -- Ripe
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84 | 10|[local::at0.16], -- 10% effaced
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85 | 20|[local::at0.17], -- 20% effaced
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86 | 30|[local::at0.18], -- 30% effaced
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87 | 40|[local::at0.19], -- 40% effaced
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88 | 50|[local::at0.20], -- Partially (50%) effaced
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89 | 60|[local::at0.21], -- 60% effaced
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90 | 70|[local::at0.22], -- 70% effaced
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91 | 80|[local::at0.23], -- 80% effaced
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92 | 90|[local::at0.24], -- 90% effaced
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93 | 100|[local::at0.25] -- Fully effaced
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94 | }
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95 | }
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96 | ELEMENT[at0.40] occurrences matches {0..1} matches { -- Thickness
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97 | value matches {
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98 | DV_CODED_TEXT matches {
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99 | defining_code matches {
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100 | [local::
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101 | at0.41, -- Thick
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102 | at0.42, -- Thin
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103 | at0.43, -- Paper-thin
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104 | at0.44] -- Oedematous
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105 | }
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106 | }
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107 | }
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108 | }
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109 | ELEMENT[at0.45] occurrences matches {0..1} matches { -- Application to presenting part
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110 | value matches {
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111 | DV_CODED_TEXT matches {
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112 | defining_code matches {
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113 | [local::
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114 | at0.46, -- Loosely applied
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115 | at0.47] -- Tightly applied
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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[at0.27] occurrences matches {0..2} matches { -- Cervical os
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121 | items cardinality matches {0..*; unordered} matches {
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122 | ELEMENT[at0.32] occurrences matches {0..1} matches { -- Site
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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 | at0.33, -- External os
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128 | at0.34] -- Internal os
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129 | }
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130 | }
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131 | }
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132 | }
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133 | CLUSTER[at0.31] occurrences matches {0..1} matches { -- Dilation
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134 | items cardinality matches {0..*; unordered} matches {
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135 | ELEMENT[at0.28] occurrences matches {0..1} matches { -- Estimate
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136 | value matches {
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137 | C_DV_QUANTITY <
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138 | property = <[openehr::122]>
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139 | list = <
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140 | ["1"] = <
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141 | units = <"cm">
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142 | magnitude = <|0.0..10.0|>
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143 | precision = <|1|>
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144 | >
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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 | ELEMENT[at0.35] occurrences matches {0..1} matches { -- Number of finger tips admitted
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150 | value matches {
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151 | DV_COUNT matches {*}
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152 | }
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153 | }
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154 | }
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155 | }
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156 | ELEMENT[at0.29] occurrences matches {0..1} matches { -- Findings
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157 | value matches {
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158 | DV_TEXT matches {*}
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159 | }
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160 | }
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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 | allow_archetype CLUSTER occurrences matches {0..*} matches {
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166 | include
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167 | archetype_id/value matches {/palpation\.v1draft/}
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168 | archetype_id/value matches {/inspection\.v1draft/}
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169 | exclude
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170 | archetype_id/value matches {/.*/}
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171 | }
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172 | CLUSTER[at0.30] occurrences matches {0..1} matches { -- Vaginal fluid
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173 | items cardinality matches {0..*; unordered} matches {
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174 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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175 | include
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176 | archetype_id/value matches {/fluid\.v1/}
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177 | }
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178 | }
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179 | }
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180 | CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail
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181 | items cardinality matches {0..*; unordered} matches {
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182 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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183 | include
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184 | archetype_id/value matches {/exam\.v1/}
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185 | archetype_id/value matches {/exam-fetus\.v1/}
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186 | }
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187 | }
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188 | }
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189 | }
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190 | }
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191 | ELEMENT[at0006] occurrences matches {0..*} matches { -- Image
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192 | value matches {
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193 | DV_MULTIMEDIA matches {
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194 | media_type matches {
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195 | [openEHR::
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196 | 426,
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197 | 427,
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198 | 429]
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199 | }
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200 | }
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201 | }
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202 | }
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203 | }
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204 | }
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205 |
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206 | ontology
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207 | term_definitions = <
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208 | ["en"] = <
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209 | items = <
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210 | ["at0.1"] = <
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211 | description = <"Information about the size of the object for examination">
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212 | text = <"Size">
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213 | >
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214 | ["at0.10"] = <
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215 | description = <"The cervix is deviated to the right">
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216 | text = <"To the right">
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217 | >
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218 | ["at0.11"] = <
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219 | description = <"The cervix is deviated to the left">
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220 | text = <"To the left">
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221 | >
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222 | ["at0.12"] = <
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223 | description = <"The cervix is anterior near the pubis">
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224 | text = <"Anterior">
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225 | >
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226 | ["at0.13"] = <
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227 | description = <"The cervix is at the back near the sacrum">
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228 | text = <"Posterior">
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229 | >
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230 | ["at0.14"] = <
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231 | description = <"The effacement of the uterine cervix in late pregnancy or labour.">
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232 | text = <"Effacement">
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233 | >
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234 | ["at0.15"] = <
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235 | description = <"The cervix has not changed its form">
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236 | text = <"Uneffaced">
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237 | >
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238 | ["at0.16"] = <
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239 | description = <"The cervix is effaced to about 10%">
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240 | text = <"10% effaced">
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241 | >
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242 | ["at0.17"] = <
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243 | description = <"The cervix is effaced to about 20%">
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244 | text = <"20% effaced">
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245 | >
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246 | ["at0.18"] = <
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247 | description = <"The cervix is effaced to about 30%">
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248 | text = <"30% effaced">
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249 | >
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250 | ["at0.19"] = <
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251 | description = <"The cervix is effaced to about 40%">
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252 | text = <"40% effaced">
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253 | >
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254 | ["at0.20"] = <
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255 | description = <"The cervix is partially effaced to about 50%">
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256 | text = <"Partially (50%) effaced">
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257 | >
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258 | ["at0.21"] = <
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259 | description = <"The cervix is effaced to about 60%">
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260 | text = <"60% effaced">
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261 | >
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262 | ["at0.22"] = <
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263 | description = <"The cervix is effaced to about 70%">
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264 | text = <"70% effaced">
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265 | >
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266 | ["at0.23"] = <
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267 | description = <"The cervix is effaced to about 80%">
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268 | text = <"80% effaced">
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269 | >
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270 | ["at0.24"] = <
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271 | description = <"The cervix is effaced to about 90%">
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272 | text = <"90% effaced">
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273 | >
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274 | ["at0.25"] = <
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275 | description = <"The cervix is fully effaced to 100%">
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276 | text = <"Fully effaced">
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277 | >
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278 | ["at0.26"] = <
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279 | description = <"The cervix is ripe and beginning to efface">
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280 | text = <"Ripe">
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281 | >
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282 | ["at0.27"] = <
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283 | description = <"The outlet of the uterus">
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284 | text = <"Cervical os">
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285 | >
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286 | ["at0.28"] = <
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287 | description = <"The dilation of the os">
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288 | text = <"Estimate">
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289 | >
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290 | ["at0.29"] = <
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291 | description = <"Findings about the cervical os">
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292 | text = <"Findings">
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293 | >
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294 | ["at0.30"] = <
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295 | description = <"Vaginal loss or discharge">
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296 | text = <"Vaginal fluid">
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297 | >
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298 | ["at0.31"] = <
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299 | description = <"Dilation of cervix">
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300 | text = <"Dilation">
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301 | >
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302 | ["at0.32"] = <
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303 | description = <"Identify part of cervix which is being examined">
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304 | text = <"Site">
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305 | >
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306 | ["at0.33"] = <
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307 | description = <"External opening of the cervix to the vagina">
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308 | text = <"External os">
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309 | >
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310 | ["at0.34"] = <
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311 | description = <"Internal opening of the cervix to the uterus">
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312 | text = <"Internal os">
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313 | >
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314 | ["at0.35"] = <
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315 | description = <"Number of finger tips that are able to be admitted into the internal or external os">
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316 | text = <"Number of finger tips admitted">
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317 | >
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318 | ["at0.36"] = <
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319 | description = <"Consistency of cervix">
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320 | text = <"Consistency">
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321 | >
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322 | ["at0.37"] = <
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323 | description = <"Soft">
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324 | text = <"Soft">
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325 | >
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326 | ["at0.38"] = <
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327 | description = <"Firm">
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328 | text = <"Firm">
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329 | >
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330 | ["at0.39"] = <
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331 | description = <"Length of cervix">
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332 | text = <"Length">
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333 | >
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334 | ["at0.40"] = <
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335 | description = <"Cervical thickness">
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336 | text = <"Thickness">
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337 | >
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338 | ["at0.41"] = <
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339 | description = <"Thick">
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340 | text = <"Thick">
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341 | >
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342 | ["at0.42"] = <
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343 | description = <"Thin">
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344 | text = <"Thin">
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345 | >
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346 | ["at0.43"] = <
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347 | description = <"Very thin">
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348 | text = <"Paper-thin">
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349 | >
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350 | ["at0.44"] = <
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351 | description = <"Thickened and swollen">
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352 | text = <"Oedematous">
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353 | >
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354 | ["at0.45"] = <
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355 | description = <"Application of cervix to fetal presenting part">
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356 | text = <"Application to presenting part">
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357 | >
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358 | ["at0.46"] = <
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359 | description = <"Not moulded to presenting part">
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360 | text = <"Loosely applied">
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361 | >
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362 | ["at0.47"] = <
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363 | description = <"Moulded to presenting part">
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364 | text = <"Tightly applied">
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365 | >
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366 | ["at0.48"] = <
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367 | description = <"*">
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368 | text = <"Labour-specific findings">
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369 | >
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370 | ["at0.8"] = <
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371 | description = <"The position in relation to the normal anatomical position">
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372 | text = <"Position">
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373 | >
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374 | ["at0.9"] = <
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375 | description = <"The cervix is central and in the normal position">
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376 | text = <"Central">
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377 | >
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378 | ["at0000"] = <
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379 | description = <"Generic examination cluster for describing a finding on physical examination">
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380 | text = <"Examination">
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381 | >
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382 | ["at0000.1"] = <
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383 | description = <"Examination findings on physical examination of the uterine cervix">
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384 | text = <"Examination of the cervix">
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385 | >
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386 | ["at0001"] = <
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387 | description = <"The object of the examination">
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388 | text = <"Object">
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389 | >
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390 | ["at0002"] = <
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391 | description = <"Textural description of the part examined">
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392 | text = <"Clinical description">
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393 | >
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394 | ["at0003"] = <
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395 | description = <"More focused examination findings">
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396 | text = <"Detail">
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397 | >
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398 | ["at0004"] = <
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399 | description = <"A group of statements about the normality of the examination">
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400 | text = <"Normal statements">
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401 | >
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402 | ["at0005"] = <
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403 | description = <"A specific statement of normality">
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404 | text = <"Normal statement">
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405 | >
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406 | ["at0006"] = <
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407 | description = <"Drawing or image of the area examined">
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408 | text = <"Image">
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409 | >
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410 | ["at0007"] = <
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411 | description = <"Information about the size of the object for examination">
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412 | text = <"Size">
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413 | >
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414 | ["at0008"] = <
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415 | description = <"Clinical findings">
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416 | text = <"Findings">
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417 | >
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418 | >
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419 | >
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420 | >
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