ARCHETYPE Palpation of the cervix (openEHR-EHR-CLUSTER.exam-palpation-cervix.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-palpation-cervix.v0
ConceptPalpation of the cervix
DescriptionFindings observed by palpation of the cervix.
UseUse to record a narrative description and clinical interpretation of the findings observed only by palpation of the cervix, including during pregnancy and labour. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-palpation-vagina or OBSERVATION.exam archetypes, but can also be used within other ENTRY 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 to record findings about the visual inspection of the cervix during a speculum examination. Use CLUSTER.exam-inspection-cervix for this purpose. Not to be used when multiple modes are used simultaneously to examine a body system or anatomical structure, including inspection or auscultation. Use the CLUSTER.exam family of archetypes for this purpose. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign.
PurposeTo record a narrative description and clinical interpretation of the findings observed only by palpation of the cervix.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2011-04-02
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2011-04-02
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics, Australia, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=6609C7E296FB56567BE8311DA2367156, build_uid=dd808879-bde0-41dc-996c-6ca3139f5cd7, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UID17d11fe9-1e67-45e7-bb58-a126a1ee7932
Language useden
Citeable Identifier1013.1.3987
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed by palpation of the cervix., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
SB Bhattacharyya, Sudisa Consultancy Services, India
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Hilde Hollås, DIPS ASA, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Ivar Mehlum, Helse Bergen HF, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Lars Morgan Karlsen, DIPS ASA, Norway
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Jussara Rotzsch, UNB, Brazil
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia (openEHR Editor)
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Jon Tysdahl, Furst medlab AS, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Anca Heyd, DIPS ASA, Norway, originalLanguage=en, translators=
  • Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF

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    openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or
    openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations or
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    • Anterior [The cervix is pointing anteriorly, towards the pubis.]
    • Normal [The cervix is located centrally, in the typical anatomical position.]
    • Posterior [The cervix is pointing posteriorly, towards the sacrum.]
    • Left [The cervix is pointing towards the left side of the pelvis.]
    • Right [The cervix is pointing towards the right side of the pelvis.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.8], code=at0.0.8, itemType=ELEMENT, level=1, text=Consistency, description=The firmness of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Firm [The cervix feels firm or hard.]
    • Intermediate [The cervix feels neither firm nor soft.]
    • Soft [The cervix feels soft or ripe.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.12], code=at0.0.12, itemType=ELEMENT, level=1, text=Surface description, description=Narrative description about the surface of the cervix., 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[at0.0.13], code=at0.0.13, itemType=ELEMENT, level=1, text=Mobility, description=Narrative description of the mobility of the cervix., 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[at0.0.14], code=at0.0.14, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description of the tenderness of the cervix, especially on movement., 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[at0.0.15], code=at0.0.15, itemType=ELEMENT, level=1, text=Thickness, description=The thickness of the cervix., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Thick [The cervix is thick.]
    • Thin [The cervix is thin.]
    • Paper-thin [The cervix is very thin.]
    • Oedematous [The cervix is thickened and swollen.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.16], code=at0.0.16, itemType=ELEMENT, level=1, text=Effacement, description=Estimation of the proportion of cervical effacement during late pregnancy or labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
    • Percent
    Numerator: 0.0..100.0
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.21], code=at0.0.21, itemType=ELEMENT, level=1, text=Cervical length, description=Estimation of the length of the cervix during late pregnancy or labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
    Units:
    • 0.0..10.0 cm
      Limit decimal places: 1
    • >=0.0 mm
      Limit decimal places: 0
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.22], code=at0.0.22, itemType=ELEMENT, level=1, text=Application to presenting part, description=Application of the cervix to the presenting part of the fetus during late pregnancy or labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Loose [Cervix is not moulded to the fetal presenting part.]
    • Tight [Cervix is closely moulded to the fetal presenting part.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.25], code=at0.0.25, itemType=ELEMENT, level=1, text=Anterior lip presence, description=The presence of an anterior lip of the cervix., 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 anterior lip is present.]
    • Absent [An anterior lip is not present.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.28], code=at0.0.28, itemType=ELEMENT, level=1, text=External os dilation, description=The amount of dilation of the external opening of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
    Units: 0.0..10.0 cm
    Limit decimal places: 0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.29], code=at0.0.29, itemType=ELEMENT, level=1, text=Internal os dilation, description=The amount of dilation of the internal opening of the cervix to the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
    Units: 0.0..10.0 cm
    Limit decimal places: 0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.30], code=at0.0.30, itemType=ELEMENT, level=1, text=Cervical os description, description=Narrative description of findings on palpation of cervical os., 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[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about 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:
    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 or
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    openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null]], other_participations=[], content=[], state=[], activities=[], data=[], relationships=[], credentials=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000.1.1, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001.0.1], code=at0001.0.1, itemType=ELEMENT, level=1, text=System or structure examined, description=Identification of the examined body system or anatomical structure., comment=Coding of the system or structure examined with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0012], code=at0012, itemType=ELEMENT, level=1, text=Body site, description=Identification of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant., 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[at0011], code=at0011, itemType=SLOT, level=1, text=Structured body site, description=A structured description of the area of the body under examination., comment=If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or
    openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations or
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    • Anterior [The cervix is pointing anteriorly, towards the pubis.]
    • Normal [The cervix is located centrally, in the typical anatomical position.]
    • Posterior [The cervix is pointing posteriorly, towards the sacrum.]
    • Left [The cervix is pointing towards the left side of the pelvis.]
    • Right [The cervix is pointing towards the right side of the pelvis.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.8], code=at0.0.8, itemType=ELEMENT, level=1, text=Consistency, description=The firmness of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Firm [The cervix feels firm or hard.]
    • Intermediate [The cervix feels neither firm nor soft.]
    • Soft [The cervix feels soft or ripe.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.12], code=at0.0.12, itemType=ELEMENT, level=1, text=Surface description, description=Narrative description about the surface of the cervix., 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[at0.0.13], code=at0.0.13, itemType=ELEMENT, level=1, text=Mobility, description=Narrative description of the mobility of the cervix., 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[at0.0.14], code=at0.0.14, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description of the tenderness of the cervix, especially on movement., 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[at0.0.15], code=at0.0.15, itemType=ELEMENT, level=1, text=Thickness, description=The thickness of the cervix., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Thick [The cervix is thick.]
    • Thin [The cervix is thin.]
    • Paper-thin [The cervix is very thin.]
    • Oedematous [The cervix is thickened and swollen.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.16], code=at0.0.16, itemType=ELEMENT, level=1, text=Effacement, description=Estimation of the proportion of cervical effacement during late pregnancy or labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
    • Percent
    Numerator: 0.0..100.0
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.21], code=at0.0.21, itemType=ELEMENT, level=1, text=Cervical length, description=Estimation of the length of the cervix during late pregnancy or labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
    Units:
    • 0.0..10.0 cm
      Limit decimal places: 1
    • >=0.0 mm
      Limit decimal places: 0
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.22], code=at0.0.22, itemType=ELEMENT, level=1, text=Application to presenting part, description=Application of the cervix to the presenting part of the fetus during late pregnancy or labour., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
    • Loose [Cervix is not moulded to the fetal presenting part.]
    • Tight [Cervix is closely moulded to the fetal presenting part.]
    , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.25], code=at0.0.25, itemType=ELEMENT, level=1, text=Anterior lip presence, description=The presence of an anterior lip of the cervix., 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 anterior lip is present.]
    • Absent [An anterior lip is not present.]
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