1 | archetype (adl_version=1.4)
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2 | openEHR-EHR-CLUSTER.exam-uterus.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 uterus
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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"] = <"Sam Heard">
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13 | ["organisation"] = <"Ocean Informatics">
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14 | ["date"] = <"08/04/2007">
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15 | ["email"] = <"sam.heard@oceaninformatics.biz">
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16 | >
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17 | details = <
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18 | ["en"] = <
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19 | language = <[ISO_639-1::en]>
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20 | purpose = <"A cluster for recording findings on physical examination of the uterus.">
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21 | use = <"">
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22 | keywords = <"examination", "physical", "uterus", "pregnancy">
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23 | misuse = <"">
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24 | >
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25 | >
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26 | lifecycle_state = <"Initial">
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27 | other_contributors = <>
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28 |
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29 | definition
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30 | CLUSTER[at0000.1] matches { -- Examination of the uterus
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31 | items cardinality matches {0..*; unordered} matches {
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32 | CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements
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33 | items cardinality matches {0..*; unordered} matches {
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34 | ELEMENT[at0005] occurrences matches {0..*} matches { -- Normal statement
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35 | value matches {
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36 | DV_TEXT matches {*}
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37 | }
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38 | }
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39 | }
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40 | }
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41 | ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description
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42 | value matches {
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43 | DV_TEXT matches {*}
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44 | }
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45 | }
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46 | CLUSTER[at0008] occurrences matches {0..1} matches { -- Findings
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47 | items cardinality matches {0..*; unordered} matches {
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48 | allow_archetype CLUSTER occurrences matches {0..*} matches {
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49 | include
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50 | archetype_id/value matches {/palpation\.v1draft/}
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51 | archetype_id/value matches {/inspection\.v1draft/}
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52 | exclude
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53 | archetype_id/value matches {/.*/}
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54 | }
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55 | ELEMENT[at0.24] occurrences matches {0..1} matches { -- Position
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56 | value matches {
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57 | DV_CODED_TEXT matches {
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58 | defining_code matches {
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59 | [local::
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60 | at0.26, -- Anteverted
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61 | at0.27] -- Retroverted
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62 | }
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63 | }
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64 | }
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65 | }
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66 | CLUSTER[at0.1] occurrences matches {0..1} matches { -- Size
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67 | items cardinality matches {0..*; unordered} matches {
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68 | ELEMENT[at0.2] occurrences matches {0..1} matches { -- Fundal height
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69 | value matches {
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70 | C_DV_QUANTITY <
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71 | property = <[openehr::122]>
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72 | list = <
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73 | ["1"] = <
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74 | units = <"cm">
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75 | magnitude = <|0.0..100.0|>
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76 | precision = <|1|>
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77 | >
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78 | >
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79 | >
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80 | }
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81 | }
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82 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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83 | include
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84 | archetype_id/value matches {/dimensions\.v1/}
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85 | archetype_id/value matches {/size\.v1draft/}
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86 | }
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87 | ELEMENT[at0.3] occurrences matches {0..1} matches { -- Weeks of gestation
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88 | value matches {
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89 | DV_DURATION matches {
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90 | value matches {PW}
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91 | }
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92 | }
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93 | }
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94 | ELEMENT[at0.20] occurrences matches {0..1} matches { -- Relative to anatomical markers
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95 | value matches {
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96 | DV_CODED_TEXT matches {
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97 | defining_code matches {
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98 | [local::
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99 | at0.21, -- At symphisis pubis
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100 | at0.22, -- At umbilicus
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101 | at0.23] -- At xiphisternum
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102 | }
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103 | }
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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[at0.4] occurrences matches {0..1} matches { -- Assessment of liquor volume
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109 | value matches {
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110 | -3|[local::at0.5], -- Markedly reduced
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111 | -2|[local::at0.6], -- Reduced
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112 | -1|[local::at0.7], -- Slightly reduced
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113 | 0|[local::at0.8], -- Normal
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114 | 1|[local::at0.9], -- Slightly increased
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115 | 2|[local::at0.10], -- Increased
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116 | 3|[local::at0.11] -- Markedly increased
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117 | }
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118 | }
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119 | ELEMENT[at0.12] occurrences matches {0..1} matches { -- Number of fetuses
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120 | value matches {
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121 | DV_COUNT matches {
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122 | magnitude matches {|>=0|}
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123 | }
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124 | }
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125 | }
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126 | CLUSTER[at0.18] occurrences matches {0..1} matches { -- Fetus
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127 | items cardinality matches {1..*; unordered} matches {
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128 | allow_archetype CLUSTER occurrences matches {0..*} matches {
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129 | include
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130 | archetype_id/value matches {/exam-fetus\.v1/}
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131 | }
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132 | }
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133 | }
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134 | CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail
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135 | items cardinality matches {0..*; unordered} matches {
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136 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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137 | include
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138 | archetype_id/value matches {/exam-generic\.v1/}
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139 | }
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140 | }
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141 | }
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142 | }
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143 | }
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144 | ELEMENT[at0006] occurrences matches {0..*} matches { -- Image
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145 | value matches {
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146 | DV_MULTIMEDIA matches {
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147 | media_type matches {
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148 | [openEHR::
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149 | 426,
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150 | 427,
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151 | 429]
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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 | }
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157 | }
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158 |
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159 | ontology
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160 | term_definitions = <
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161 | ["en"] = <
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162 | items = <
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163 | ["at0.1"] = <
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164 | description = <"Information about the size of the object for examination">
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165 | text = <"Size">
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166 | >
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167 | ["at0.10"] = <
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168 | description = <"The amount of liquor is definitely increased">
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169 | text = <"Increased">
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170 | >
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171 | ["at0.11"] = <
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172 | description = <"The amount of liquor is greatly increased compared to normal for gestation">
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173 | text = <"Markedly increased">
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174 | >
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175 | ["at0.12"] = <
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176 | description = <"The number of foetuses that are in the uterus">
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177 | text = <"Number of fetuses">
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178 | >
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179 | ["at0.18"] = <
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180 | description = <"Information about one or more foetuses">
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181 | text = <"Fetus">
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182 | >
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183 | ["at0.19"] = <
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184 | description = <"An optional identifier of the fetus">
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185 | text = <"Identifier">
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186 | >
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187 | ["at0.2"] = <
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188 | description = <"The height of the uterine fundus measured from the symphysis pubis">
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189 | text = <"Fundal height">
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190 | >
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191 | ["at0.20"] = <
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192 | description = <"Relative size of uterus related to anatomy of person">
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193 | text = <"Relative to anatomical markers">
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194 | >
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195 | ["at0.21"] = <
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196 | description = <"*">
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197 | text = <"At symphisis pubis">
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198 | >
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199 | ["at0.22"] = <
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200 | description = <"*">
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201 | text = <"At umbilicus">
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202 | >
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203 | ["at0.23"] = <
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204 | description = <"*">
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205 | text = <"At xiphisternum">
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206 | >
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207 | ["at0.24"] = <
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208 | description = <"Position of uterus">
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209 | text = <"Position">
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210 | >
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211 | ["at0.25"] = <
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212 | description = <"Position of uterus">
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213 | text = <"Position">
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214 | >
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215 | ["at0.26"] = <
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216 | description = <"Uterine fundus is tipped forward">
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217 | text = <"Anteverted">
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218 | >
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219 | ["at0.27"] = <
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220 | description = <"Uterine fundus is tipped backward">
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221 | text = <"Retroverted">
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222 | >
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223 | ["at0.28"] = <
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224 | description = <"*">
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225 | text = <"New element">
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226 | >
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227 | ["at0.3"] = <
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228 | description = <"The size in terms of weeks of pregnancy">
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229 | text = <"Weeks of gestation">
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230 | >
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231 | ["at0.4"] = <
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232 | description = <"The relative amount of liquor present in the uterus">
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233 | text = <"Assessment of liquor volume">
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234 | >
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235 | ["at0.5"] = <
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236 | description = <"The amount of liquor is much less than expected">
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237 | text = <"Markedly reduced">
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238 | >
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239 | ["at0.6"] = <
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240 | description = <"The amount of liquor is definitely reduced">
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241 | text = <"Reduced">
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242 | >
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243 | ["at0.7"] = <
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244 | description = <"The amount of liquor is slightly reduced">
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245 | text = <"Slightly reduced">
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246 | >
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247 | ["at0.8"] = <
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248 | description = <"The amount of liquor is normal for gestation">
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249 | text = <"Normal">
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250 | >
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251 | ["at0.9"] = <
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252 | description = <"The amount of liquor is slightly increased">
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253 | text = <"Slightly increased">
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254 | >
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255 | ["at0000"] = <
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256 | description = <"Generic examination cluster for describing a finding on physical examination">
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257 | text = <"Examination">
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258 | >
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259 | ["at0000.1"] = <
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260 | description = <"For recording findings of the uterus including when pregnant">
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261 | text = <"Examination of the uterus">
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262 | >
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263 | ["at0001"] = <
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264 | description = <"The object of the examination">
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265 | text = <"Object">
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266 | >
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267 | ["at0002"] = <
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268 | description = <"Textural description of the part examined">
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269 | text = <"Clinical description">
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270 | >
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271 | ["at0003"] = <
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272 | description = <"More focused examination findings">
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273 | text = <"Detail">
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274 | >
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275 | ["at0004"] = <
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276 | description = <"A group of statements about the normality of the examination">
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277 | text = <"Normal statements">
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278 | >
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279 | ["at0005"] = <
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280 | description = <"A specific statement of normality">
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281 | text = <"Normal statement">
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282 | >
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283 | ["at0006"] = <
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284 | description = <"Drawing or image of the area examined">
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285 | text = <"Image">
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286 | >
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287 | ["at0008"] = <
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288 | description = <"Clinical findings">
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289 | text = <"Findings">
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290 | >
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291 | >
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292 | >
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293 | >
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