ARCHETYPE Inspection of cervix (openEHR-EHR-CLUSTER.inspection_cervix.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.inspection_cervix.v0
ConceptInspection of cervix
DescriptionFindings observed during the inspection of the cervix.
UseUse to record a narrative description of the overall findings observed during the physical inspection of the cervix. This initial draft archetype consists only of the core examination pattern data elements (as per CLUSTER.exam_pattern) and will likely be expanded further over time as specific clinical requirements are identified. This archetype has been specifically designed to be used in the 'Examination findings' SLOT within the CLUSTER.inspection_vagina archetype or the OBSERVATION.exam, but can also be used within any other OBSERVATION or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
MisuseNot to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom. Not to be used to record stand-alone clinical observations or measurements or test results - use specific OBSERVATION archetypes. For example OBSERVATION.blood_pressure or OBSERVATION.imaging_exam.
PurposeFor recording a narrative description and clinical interpretation of the findings observed during the inspection of the cervix.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT, Norway
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2015-06-08
Other Details LanguageAuthor name: Silje Ljosland Bakke
Organisation: Nasjonal IKT, Norway
Email: silje.ljosland.bakke@nasjonalikt.no
Date originally authored: 2015-06-08
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=BEF09C151F030592ED74D24B7556230A, build_uid=04322c18-1416-4e59-92be-382981144e36, revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDa4bb0f04-72e6-4562-9257-8521d3742508
Language useden
Citeable Identifier1013.1.2095
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed during the inspection of the cervix., archetypeConceptComment=null, otherContributors=Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
John Tore Valand, Haukeland Universitetssjukehus, Norway
Heather Leslie, Atomica Informatics, Australia, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={details=[], identities=[], source=[], credentials=[], context=[], description=[], ism_transition=[], events=[], content=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0013], code=at0013, itemType=ELEMENT, level=1, text=Discharge category, description=Type of cervical discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Clear [The cervical discharge is clear in appearance.]
  • Mucopurulent [The cervical discharge is mucopurulent in appearance.]
  • Brick-coloured [The cervical discharge is brick-coloured in appearance.]
  • Fresh bleeding [The cervical discharge is fresh blood.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=ELEMENT, level=1, text=Discharge present, description=The presence of cervical discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A cervical discharge was present.]
  • Absent [A cervical discharge was not present.]
  • Indeterminate [It was not possible to determine if a cervical discharge was present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0036], code=at0036, itemType=ELEMENT, level=1, text=Discharge description, description=Narrative description about the cervical discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0020], code=at0020, itemType=ELEMENT, level=1, text=Ectropion present, description=The presence or absence of cervical ectopia., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [An ectropion was present.]
  • Absent [An ectropion was not present.]
  • Indeterminate [It was not possible to determine if an ectropion was present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0021], code=at0021, itemType=ELEMENT, level=1, text=Ectropion description, description=Narrative description about the cervical ectropion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022], code=at0022, itemType=CLUSTER, level=1, text=Lesions, description=Structured elements relating to other specific findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0023], code=at0023, itemType=ELEMENT, level=2, text=Lesion name, description=Identification of the lesion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Warts [A genital wart.]
  • Tumour [A lump or tumour.]
  • Nabothian cyst [A Nabothian cyst.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0028], code=at0028, itemType=ELEMENT, level=2, text=Presence, description=The presence or absence of the specified finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The lesion/s were present.]
  • Absent [The lesion/s were not present.]
  • Indeterminate [It was not possible to determine if the lesions were present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the specific finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Number, description=The number of the specified finding observed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Site, description=The site where the specified finding is observed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0032], code=at0032, itemType=SLOT, level=2, text=Structured anatomical location, description=A structured anatomical location of the finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0005], code=at0005, itemType=SLOT, level=1, text=Multimedia representation, description=Digital image, video or diagram representing the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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  • Clear [The cervical discharge is clear in appearance.]
  • Mucopurulent [The cervical discharge is mucopurulent in appearance.]
  • Brick-coloured [The cervical discharge is brick-coloured in appearance.]
  • Fresh bleeding [The cervical discharge is fresh blood.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=ELEMENT, level=1, text=Discharge present, description=The presence of cervical discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [A cervical discharge was present.]
  • Absent [A cervical discharge was not present.]
  • Indeterminate [It was not possible to determine if a cervical discharge was present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0036], code=at0036, itemType=ELEMENT, level=1, text=Discharge description, description=Narrative description about the cervical discharge., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0020], code=at0020, itemType=ELEMENT, level=1, text=Ectropion present, description=The presence or absence of cervical ectopia., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [An ectropion was present.]
  • Absent [An ectropion was not present.]
  • Indeterminate [It was not possible to determine if an ectropion was present or absent.]
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  • Warts [A genital wart.]
  • Tumour [A lump or tumour.]
  • Nabothian cyst [A Nabothian cyst.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0028], code=at0028, itemType=ELEMENT, level=2, text=Presence, description=The presence or absence of the specified finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [The lesion/s were present.]
  • Absent [The lesion/s were not present.]
  • Indeterminate [It was not possible to determine if the lesions were present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0029], code=at0029, itemType=ELEMENT, level=2, text=Description, description=Narrative description about the specific finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0030], code=at0030, itemType=ELEMENT, level=2, text=Number, description=The number of the specified finding observed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0031], code=at0031, itemType=ELEMENT, level=2, text=Site, description=The site where the specified finding is observed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0022]/items[at0032], code=at0032, itemType=SLOT, level=2, text=Structured anatomical location, description=A structured anatomical location of the finding., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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