archetype (adl_version=1.4) openEHR-EHR-CLUSTER.exam-uterus.v1 specialize openEHR-EHR-CLUSTER.exam.v1 concept [at0000.1] -- Examination of the uterus language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Sam Heard"> ["organisation"] = <"Ocean Informatics"> ["date"] = <"08/04/2007"> ["email"] = <"sam.heard@oceaninformatics.biz"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"A cluster for recording findings on physical examination of the uterus."> use = <""> keywords = <"examination", "physical", "uterus", "pregnancy"> misuse = <""> > > lifecycle_state = <"Initial"> other_contributors = <> definition CLUSTER[at0000.1] matches { -- Examination of the uterus items cardinality matches {0..*; unordered} matches { CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements items cardinality matches {0..*; unordered} matches { ELEMENT[at0005] occurrences matches {0..*} matches { -- Normal statement value matches { DV_TEXT matches {*} } } } } ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description value matches { DV_TEXT matches {*} } } CLUSTER[at0008] occurrences matches {0..1} matches { -- Findings items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..*} matches { include archetype_id/value matches {/palpation\.v1draft/} archetype_id/value matches {/inspection\.v1draft/} exclude archetype_id/value matches {/.*/} } ELEMENT[at0.24] occurrences matches {0..1} matches { -- Position value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.26, -- Anteverted at0.27] -- Retroverted } } } } CLUSTER[at0.1] occurrences matches {0..1} matches { -- Size items cardinality matches {0..*; unordered} matches { ELEMENT[at0.2] occurrences matches {0..1} matches { -- Fundal height value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"cm"> magnitude = <|0.0..100.0|> precision = <|1|> > > > } } allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/dimensions\.v1/} archetype_id/value matches {/size\.v1draft/} } ELEMENT[at0.3] occurrences matches {0..1} matches { -- Weeks of gestation value matches { DV_DURATION matches { value matches {PW} } } } ELEMENT[at0.20] occurrences matches {0..1} matches { -- Relative to anatomical markers value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.21, -- At symphisis pubis at0.22, -- At umbilicus at0.23] -- At xiphisternum } } } } } } ELEMENT[at0.4] occurrences matches {0..1} matches { -- Assessment of liquor volume value matches { -3|[local::at0.5], -- Markedly reduced -2|[local::at0.6], -- Reduced -1|[local::at0.7], -- Slightly reduced 0|[local::at0.8], -- Normal 1|[local::at0.9], -- Slightly increased 2|[local::at0.10], -- Increased 3|[local::at0.11] -- Markedly increased } } ELEMENT[at0.12] occurrences matches {0..1} matches { -- Number of fetuses value matches { DV_COUNT matches { magnitude matches {|>=0|} } } } CLUSTER[at0.18] occurrences matches {0..1} matches { -- Fetus items cardinality matches {1..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..*} matches { include archetype_id/value matches {/exam-fetus\.v1/} } } } CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/exam-generic\.v1/} } } } } } ELEMENT[at0006] occurrences matches {0..*} matches { -- Image value matches { DV_MULTIMEDIA matches { media_type matches { [openEHR:: 426, 427, 429] } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0.1"] = < description = <"Information about the size of the object for examination"> text = <"Size"> > ["at0.10"] = < description = <"The amount of liquor is definitely increased"> text = <"Increased"> > ["at0.11"] = < description = <"The amount of liquor is greatly increased compared to normal for gestation"> text = <"Markedly increased"> > ["at0.12"] = < description = <"The number of foetuses that are in the uterus"> text = <"Number of fetuses"> > ["at0.18"] = < description = <"Information about one or more foetuses"> text = <"Fetus"> > ["at0.19"] = < description = <"An optional identifier of the fetus"> text = <"Identifier"> > ["at0.2"] = < description = <"The height of the uterine fundus measured from the symphysis pubis"> text = <"Fundal height"> > ["at0.20"] = < description = <"Relative size of uterus related to anatomy of person"> text = <"Relative to anatomical markers"> > ["at0.21"] = < description = <"*"> text = <"At symphisis pubis"> > ["at0.22"] = < description = <"*"> text = <"At umbilicus"> > ["at0.23"] = < description = <"*"> text = <"At xiphisternum"> > ["at0.24"] = < description = <"Position of uterus"> text = <"Position"> > ["at0.25"] = < description = <"Position of uterus"> text = <"Position"> > ["at0.26"] = < description = <"Uterine fundus is tipped forward"> text = <"Anteverted"> > ["at0.27"] = < description = <"Uterine fundus is tipped backward"> text = <"Retroverted"> > ["at0.28"] = < description = <"*"> text = <"New element"> > ["at0.3"] = < description = <"The size in terms of weeks of pregnancy"> text = <"Weeks of gestation"> > ["at0.4"] = < description = <"The relative amount of liquor present in the uterus"> text = <"Assessment of liquor volume"> > ["at0.5"] = < description = <"The amount of liquor is much less than expected"> text = <"Markedly reduced"> > ["at0.6"] = < description = <"The amount of liquor is definitely reduced"> text = <"Reduced"> > ["at0.7"] = < description = <"The amount of liquor is slightly reduced"> text = <"Slightly reduced"> > ["at0.8"] = < description = <"The amount of liquor is normal for gestation"> text = <"Normal"> > ["at0.9"] = < description = <"The amount of liquor is slightly increased"> text = <"Slightly increased"> > ["at0000"] = < description = <"Generic examination cluster for describing a finding on physical examination"> text = <"Examination"> > ["at0000.1"] = < description = <"For recording findings of the uterus including when pregnant"> text = <"Examination of the uterus"> > ["at0001"] = < description = <"The object of the examination"> text = <"Object"> > ["at0002"] = < description = <"Textural description of the part examined"> text = <"Clinical description"> > ["at0003"] = < description = <"More focused examination findings"> text = <"Detail"> > ["at0004"] = < description = <"A group of statements about the normality of the examination"> text = <"Normal statements"> > ["at0005"] = < description = <"A specific statement of normality"> text = <"Normal statement"> > ["at0006"] = < description = <"Drawing or image of the area examined"> text = <"Image"> > ["at0008"] = < description = <"Clinical findings"> text = <"Findings"> > > > >