| 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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