All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings observed by palpation of the uterus., 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 Sam Heard, Ocean Health Systems, Australia, originalLanguage=en, translators=Norwegian Bokmål: Silje Ljosland Bakke, Nasjonal IKT HF , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], events=[], details=[], provider=[], items=[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 openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], 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. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., 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[at0004.0.1], code=at0004.0.1, 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: openEHR-EHR-CLUSTER.fetus_abdominal.v0, 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 openEHR-EHR-CLUSTER.multimedia.v0 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=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., 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: openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.2], code=at0.0.2, itemType=ELEMENT, level=1, text=Fundal measurement, description=Measured height of the uterus from symphysis pubis to uterine fundus., comment=Usually only possible in pregnancy after approximately 20 weeks of gestation., 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: cm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.4], code=at0.0.4, itemType=ELEMENT, level=1, text=Size estimation ( weeks of gestation), description=Size estimation of the uterus, expressed as the equivalent number of weeks of gestation in a typical pregnancy., comment=For exampe: an 8-week sized uterus; or a 28-week sized uterus., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: weeks >=0 weeks , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.5], code=at0.0.5, itemType=ELEMENT, level=1, text=Size estimation (anatomical), description=Description of the size of the uterus, relative to anatomical landmarks., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.6::Not palpable [Uterus is not palpable in the abdomen.]
- at0.0.7::At pubic symphysis [The uterus is just palpable at the level of the symphysis pubis.]
- at0.0.8::At umbilicus [The uterus is palpable at, or about, the level of the umbilicus.]
- at0.0.9::At xiphisternum [The uterus is palpable at, or about, the level of the xiphisternum.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.10], code=at0.0.10, itemType=ELEMENT, level=1, text=Position of the uterus, description=The position of the uterus, relative to 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=- at0.0.11::Anteverted [The uterine fundus is tipped forward, towards the abdomen.]
- at0.0.12::Neutral [The uterus is in a neutral, upright position.]
- at0.0.13::Retroverted [The uterine fundus is tipped backward, towards the back.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.14], code=at0.0.14, itemType=ELEMENT, level=1, text=Mobility, description=Description about the mobility of the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.15::Mobile [The uterus is moveable.]
- at0.0.16::Fixed [The uterus is immovable.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.17], code=at0.0.17, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description about findings of pain or tenderness of the uterus., 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[at0.0.18], code=at0.0.18, itemType=ELEMENT, level=1, text=Consistency, description=Narrative description about the texture and firmness of the uterus., 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[at0.0.19], code=at0.0.19, itemType=ELEMENT, level=1, text=Liquor estimation, description=Estimation of the relative amount of liquor present in advanced pregnancy., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.20::Decreased [The amount of liquor appears less than expected, compared to a typical pregnancy at the same gestation.]
- at0.0.21::Normal [The amount of liquor is as expected, compared to a typical pregnancy at the same gestation.]
- at0.0.22::Increased [The amount of liquor appears more than expected, compared to a typical pregnancy at the same gestation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.23], code=at0.0.23, itemType=ELEMENT, level=1, text=Number of babies, description=The number of fetuses identified on palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.24::Single [There is one baby present.]
- at0.0.25::Twins [There are two babies present.]
- at0.0.26::Multiple [There are more than two babies present.]
, extendedValues=null]], description=[], protocol=[], ism_transition=[], context=[], data=[], activities=[], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, 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= (Cardinality: 1..*, unordered), 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 openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], 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. 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or a 28-week sized uterus., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: weeks >=0 weeks , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.5], code=at0.0.5, itemType=ELEMENT, level=1, text=Size estimation (anatomical), description=Description of the size of the uterus, relative to anatomical landmarks., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.6::Not palpable [Uterus is not palpable in the abdomen.]
- at0.0.7::At pubic symphysis [The uterus is just palpable at the level of the symphysis pubis.]
- at0.0.8::At umbilicus [The uterus is palpable at, or about, the level of the umbilicus.]
- at0.0.9::At xiphisternum [The uterus is palpable at, or about, the level of the xiphisternum.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.10], code=at0.0.10, itemType=ELEMENT, level=1, text=Position of the uterus, description=The position of the uterus, relative to 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=- at0.0.11::Anteverted [The uterine fundus is tipped forward, towards the abdomen.]
- at0.0.12::Neutral [The uterus is in a neutral, upright position.]
- at0.0.13::Retroverted [The uterine fundus is tipped backward, towards the back.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.14], code=at0.0.14, itemType=ELEMENT, level=1, text=Mobility, description=Description about the mobility of the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.15::Mobile [The uterus is moveable.]
- at0.0.16::Fixed [The uterus is immovable.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.17], code=at0.0.17, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description about findings of pain or tenderness of the uterus., 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[at0.0.18], code=at0.0.18, itemType=ELEMENT, level=1, text=Consistency, description=Narrative description about the texture and firmness of the uterus., 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[at0.0.19], code=at0.0.19, itemType=ELEMENT, level=1, text=Liquor estimation, description=Estimation of the relative amount of liquor present in advanced pregnancy., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.20::Decreased [The amount of liquor appears less than expected, compared to a typical pregnancy at the same gestation.]
- at0.0.21::Normal [The amount of liquor is as expected, compared to a typical pregnancy at the same gestation.]
- at0.0.22::Increased [The amount of liquor appears more than expected, compared to a typical pregnancy at the same gestation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.0.23], code=at0.0.23, itemType=ELEMENT, level=1, text=Number of babies, description=The number of fetuses identified on palpation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=- at0.0.24::Single [There is one baby present.]
- at0.0.25::Twins [There are two babies present.]
- at0.0.26::Multiple [There are more than two babies present.]
, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |