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

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-palpation-uterus.v0
ConceptPalpation of the uterus
DescriptionFindings observed by palpation of the uterus.
UseUse to record a narrative description and clinical interpretation of the findings observed only by palpation of the uterus, either from an abdominal or a vaginal approach and including findings about the pregnant uterus. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-abdomen, 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 - for example, a fetus. 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 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 uterus, either from an abdominal or a vaginal approach.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-04-08
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-04-08
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=6EA86C4D78428E2E7AD682659ADCD744, build_uid=846288a4-e1df-45b4-8ad5-ff99b9cceb30, 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}
Keywordsuterus, fetus, foetus, baby, abdomen, vagina, pregnant, pregnancy
Lifecyclein_development
UID901e9366-1ad0-4689-b19a-2ae771052eb2
Language useden
Citeable Identifier1013.1.3996
Revision Number0.0.1-alpha
AllArchetype [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

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    • Not palpable [Uterus is not palpable in the abdomen.]
    • At pubic symphysis [The uterus is just palpable at the level of the symphysis pubis.]
    • At umbilicus [The uterus is palpable at, or about, the level of the umbilicus.]
    • 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=
    • Anteverted [The uterine fundus is tipped forward, towards the abdomen.]
    • Neutral [The uterus is in a neutral, upright position.]
    • 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=
    • Mobile [The uterus is moveable.]
    • 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=
    • Decreased [The amount of liquor appears less than expected, compared to a typical pregnancy at the same gestation.]
    • Normal [The amount of liquor is as expected, compared to a typical pregnancy at the same gestation.]
    • 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=
    • Single [There is one baby present.]
    • Twins [There are two babies present.]
    • Multiple [There are more than two babies present.]
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    • Not palpable [Uterus is not palpable in the abdomen.]
    • At pubic symphysis [The uterus is just palpable at the level of the symphysis pubis.]
    • At umbilicus [The uterus is palpable at, or about, the level of the umbilicus.]
    • 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=
    • Anteverted [The uterine fundus is tipped forward, towards the abdomen.]
    • Neutral [The uterus is in a neutral, upright position.]
    • 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=
    • Mobile [The uterus is moveable.]
    • 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=
    • Decreased [The amount of liquor appears less than expected, compared to a typical pregnancy at the same gestation.]
    • Normal [The amount of liquor is as expected, compared to a typical pregnancy at the same gestation.]
    • 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=
    • Single [There is one baby present.]
    • Twins [There are two babies present.]
    • Multiple [There are more than two babies present.]
    , extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]