archetype (adl_version=1.4) openEHR-EHR-CLUSTER.exam-fetus.v1 specialize openEHR-EHR-CLUSTER.exam.v1 concept [at0000.1] -- Examination of the fetus language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"unknown"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"For recording findings on physical examination relating to the fetus while in the uterus"> use = <""> keywords = <"foetus", "fetal", "foetal"> misuse = <""> > > lifecycle_state = <"Initial"> other_contributors = <> definition CLUSTER[at0000.1] matches { -- Examination of the fetus 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 { ELEMENT[at0.4] occurrences matches {0..1} matches { -- Lie of the fetus value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.5, -- Longitudinal at0.6, -- Transverse at0.7] -- Oblique } } } } ELEMENT[at0.8] occurrences matches {0..1} matches { -- Presentation value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.9, -- Cephalic at0.10, -- Breech at0.11, -- Full breech at0.12, -- Extended breech at0.13, -- Shoulder at0.69, -- Footling breech at0.70, -- Face at0.71, -- Cord at0.72] -- Compound } } } } ELEMENT[at0.42] occurrences matches {0..1} matches { -- Position value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.43, -- Right Occipito-transverse at0.44, -- Right Occipito-anterior at0.45, -- Right Occipito-posterior at0.46, -- Occipito-anterior at0.47, -- Occipito-posterior at0.48, -- Left Occipito-transverse at0.49, -- Left Occipito-anterior at0.50, -- Left Occipito-posterior at0.51, -- Right Sacro-transverse at0.52, -- Right Sacro-anterior at0.53, -- Right Sacro-posterior at0.54, -- Sacro-Anterior at0.55, -- Sacro-Posterior at0.56, -- Left Sacro-transverse at0.57, -- Left Sacro-anterior at0.58, -- Left Sacro-posterior at0.59, -- Right Mento-transverse at0.60, -- Right Mento-anterior at0.61, -- Right Mento-posterior at0.62, -- Mento-Anterior at0.63, -- Mento-Posterior at0.64, -- Left Mento-transverse at0.65, -- Left Mento-anterior at0.61] -- Right Mento-posterior } } } } ELEMENT[at0.32] occurrences matches {0..1} matches { -- Attitude value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.33, -- Flexed at0.34, -- Deflexed at0.35] -- Extended } } } } CLUSTER[at0.74] occurrences matches {0..1} matches { -- Engagement items cardinality matches {0..*; unordered} matches { ELEMENT[at0.22] occurrences matches {0..1} matches { -- Fifths value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.23, -- Not engaged (0/5) at0.24, -- 1/5 at0.25, -- 2/5 at0.26, -- 3/5 at0.27, -- 4/5 at0.28] -- Fully engaged (5/5) } } } } ELEMENT[at0.75] occurrences matches {0..1} matches { -- Qualitative value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.76, -- High and mobile at0.77, -- At pelvic brim at0.78] -- Engaged } } } } } } ELEMENT[at0.14] occurrences matches {0..1} matches { -- Size relative to gestation value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.15, -- Small for dates at0.67, -- ? small for dates at0.16, -- Normal at0.68, -- ? large for dates at0.17] -- Large for dates } } } } ELEMENT[at0.29] occurrences matches {0..1} matches { -- Station value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"cm"> magnitude = <|-5.0..5.0|> precision = <|0|> > > > } } ELEMENT[at0.18] occurrences matches {0..1} matches { -- Estimated fetal weight value matches { C_DV_QUANTITY < property = <[openehr::124]> list = < ["1"] = < units = <"kg"> magnitude = <|0.0..20.0|> > ["2"] = < units = <"gm"> magnitude = <|0.0..20000.0|> precision = <|0|> > > > } } CLUSTER[at0007] occurrences matches {0..1} matches { -- Size items cardinality matches {0..*; unordered} matches { allow_archetype CLUSTER occurrences matches {0..1} matches { include archetype_id/value matches {/dimensions\.v1/} archetype_id/value matches {/size\.v1draft/} } } } 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\.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 = < ["at0.10"] = < description = <"The breech is the presenting part"> text = <"Breech"> > ["at0.11"] = < description = <"The breech is presenting with the legs flexed"> text = <"Full breech"> > ["at0.12"] = < description = <"The breech is the presenting part with the leg(s) extended"> text = <"Extended breech"> > ["at0.13"] = < description = <"The shoulder is the presenting part"> text = <"Shoulder"> > ["at0.14"] = < description = <"The apparent size of the baby relative to normal for gestation"> text = <"Size relative to gestation"> > ["at0.15"] = < description = <"The size of the baby is smaller than expected for gestation"> text = <"Small for dates"> > ["at0.16"] = < description = <"The size of the baby is normal for gestation"> text = <"Normal"> > ["at0.17"] = < description = <"The size of the baby is larger than expected for gestation"> text = <"Large for dates"> > ["at0.18"] = < description = <"The estimated weight of the baby on examination"> text = <"Estimated fetal weight"> > ["at0.19"] = < description = <"The position of the head in relation to the pelvis"> text = <"Denominator"> > ["at0.20"] = < description = <"The occiput is anterior rotated to the anterior"> text = <"Left occipito-anterior"> > ["at0.21"] = < description = <"The occiput is at the back"> text = <"Occipito-posterior"> > ["at0.22"] = < description = <"The proportion of the presenting part which is felt above the pelvis"> text = <"Fifths"> > ["at0.23"] = < description = <"The head is not engaged in the pelvis"> text = <"Not engaged (0/5)"> > ["at0.24"] = < description = <"About 20% of the head is inside the pelvis"> text = <"1/5"> > ["at0.25"] = < description = <"About 40% of the head is inside the pelvis"> text = <"2/5"> > ["at0.26"] = < description = <"About 60% of the head is inside the pelvis"> text = <"3/5"> > ["at0.27"] = < description = <"About 80% of the head is inside the pelvis"> text = <"4/5"> > ["at0.28"] = < description = <"The head is inside the pelvis"> text = <"Fully engaged (5/5)"> > ["at0.29"] = < description = <"Posiiton relative to the ischial spines (minus is above, 0 is at the spines and plus is below)"> text = <"Station"> > ["at0.30"] = < description = <"The occiput is adjacent to the symphasis pubis"> text = <"Occipito-anterior"> > ["at0.31"] = < description = <"The occiput is anterior rotated to the right"> text = <"Right occipito-anterior"> > ["at0.32"] = < description = <"The degree of flexion of the body"> text = <"Attitude"> > ["at0.33"] = < description = <"The fetus is fully flexed"> text = <"Flexed"> > ["at0.34"] = < description = <"The fetus is not flexed"> text = <"Deflexed"> > ["at0.35"] = < description = <"The fetus is extended"> text = <"Extended"> > ["at0.36"] = < description = <"The occiput is on the left"> text = <"Left occipito-transverse"> > ["at0.37"] = < description = <"The occiput is on the right"> text = <"Right occipito-transverse"> > ["at0.38"] = < description = <"*"> text = <"Position"> > ["at0.39"] = < description = <"The occipital bone"> text = <"Occipito"> > ["at0.4"] = < description = <"The position of the fetus"> text = <"Lie of the fetus"> > ["at0.40"] = < description = <"The chin"> text = <"Mento"> > ["at0.41"] = < description = <"The sacral bone"> text = <"Sacro"> > ["at0.42"] = < description = <"The orientation of the denominator"> text = <"Position"> > ["at0.43"] = < description = <"The occiput is towards the right"> text = <"Right Occipito-transverse"> > ["at0.44"] = < description = <"The occiput is towards the right and anterior"> text = <"Right Occipito-anterior"> > ["at0.45"] = < description = <"The occiput is to the right and posterior"> text = <"Right Occipito-posterior"> > ["at0.46"] = < description = <"The occiput is towards the symphasis"> text = <"Occipito-anterior"> > ["at0.47"] = < description = <"The occiput is towards the sacrum"> text = <"Occipito-posterior"> > ["at0.48"] = < description = <"The occiput is towards the left"> text = <"Left Occipito-transverse"> > ["at0.49"] = < description = <"The occiput is to the left and symphasis"> text = <"Left Occipito-anterior"> > ["at0.5"] = < description = <"The lie is along the line of the mother's spine"> text = <"Longitudinal"> > ["at0.50"] = < description = <"The occiput is to the left and posterior"> text = <"Left Occipito-posterior"> > ["at0.51"] = < description = <"The fetal sacrum is towards the right"> text = <"Right Sacro-transverse"> > ["at0.52"] = < description = <"The fetal sacrum is towards the right and anterior"> text = <"Right Sacro-anterior"> > ["at0.53"] = < description = <"The fetal sacrum is to the right and posterior"> text = <"Right Sacro-posterior"> > ["at0.54"] = < description = <"The fetal sacrum is towards the symphasis"> text = <"Sacro-Anterior"> > ["at0.55"] = < description = <"The fetal sacrum is towards the sacrum"> text = <"Sacro-Posterior"> > ["at0.56"] = < description = <"The fetal sacrum is towards the left"> text = <"Left Sacro-transverse"> > ["at0.57"] = < description = <"The fetal sacrum is to the left and symphasis"> text = <"Left Sacro-anterior"> > ["at0.58"] = < description = <"The fetal sacrum is to the left and posterior"> text = <"Left Sacro-posterior"> > ["at0.59"] = < description = <"The fetal chin is towards the right"> text = <"Right Mento-transverse"> > ["at0.6"] = < description = <"The lie is perpendicular to the mother's spine"> text = <"Transverse"> > ["at0.60"] = < description = <"The fetal chin is towards the right and anterior"> text = <"Right Mento-anterior"> > ["at0.61"] = < description = <"The fetal chin is to the right and posterior"> text = <"Right Mento-posterior"> > ["at0.62"] = < description = <"The fetal chin is towards the symphasis"> text = <"Mento-Anterior"> > ["at0.63"] = < description = <"The fetal chin is towards the sacrum"> text = <"Mento-Posterior"> > ["at0.64"] = < description = <"The fetal chin is towards the left"> text = <"Left Mento-transverse"> > ["at0.65"] = < description = <"The fetal chin is to the left and symphasis"> text = <"Left Mento-anterior"> > ["at0.66"] = < description = <"The fetal chin is to the left and posterior"> text = <"Left Mento-posterior"> > ["at0.67"] = < description = <"Possibly small for this gestation"> text = <"? small for dates"> > ["at0.68"] = < description = <"Possibly larger than expected for this gestation"> text = <"? large for dates"> > ["at0.69"] = < description = <"A fetal foot is extended and presenting"> text = <"Footling breech"> > ["at0.7"] = < description = <"The lie is oblique to the mother's spine"> text = <"Oblique"> > ["at0.70"] = < description = <"The head is extended and the face is presenting"> text = <"Face"> > ["at0.71"] = < description = <"The umbilical cord is presenting"> text = <"Cord"> > ["at0.72"] = < description = <"There is a compound presentation"> text = <"Compound"> > ["at0.73"] = < description = <"*"> text = <"Station"> > ["at0.74"] = < description = <"Estimation of presenting part in relation to pelvic brim"> text = <"Engagement"> > ["at0.75"] = < description = <"Description of engagement of fetal head"> text = <"Qualitative"> > ["at0.76"] = < description = <"*"> text = <"High and mobile"> > ["at0.77"] = < description = <"*"> text = <"At pelvic brim"> > ["at0.78"] = < description = <"*"> text = <"Engaged"> > ["at0.79"] = < description = <"*"> text = <"Estimation"> > ["at0.8"] = < description = <"The presenting part of the fetus"> text = <"Presentation"> > ["at0.9"] = < description = <"The head is the presenting part"> text = <"Cephalic"> > ["at0000"] = < description = <"Generic examination cluster for describing a finding on physical examination"> text = <"Examination"> > ["at0000.1"] = < description = <"Examination cluster for describing a finding on physical examination of a fetus"> text = <"Examination of the fetus"> > ["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"> > ["at0007"] = < description = <"Information about the size of the object for examination"> text = <"Size"> > ["at0008"] = < description = <"Clinical findings"> text = <"Findings"> > > > >