Use to record structured details about a single identified physical site on or within the human body.
In many situations, a simple data element such as ‘Location of measurement’ or ‘Body site’ will be sufficient and practical when the value set is straightforward. This archetype is intended for cases where a more detailed or structured representation of an anatomical site is required, including precise or compound descriptions. It can be nested within relevant ENTRY or CLUSTER archetypes such as those for symptoms, findings, or interventions to support multiaxial or postcoordinated anatomical expressions. Examples include documenting pain in the lower limb, tenderness at McBurney’s point, or a laceration on the palmar aspect of the proximal right thumb.
The ‘Laterality' data element may be used to qualify whether a paired structure or region is affected on the left, right, or both sides. When involvement is symmetrical and equivalent on both sides, for example the same cancer in both lungs or similar pain in both legs, record 'Left and right’. However, when the clinical characteristics differ between sides, two separate instances should be used:
- Two parallel instances of this archetype within the same SLOT, each with its own laterality and specific details. For example, documenting equal tumours in the lower left lung lobe and the upper right lung lobe.
- Two parallel instances of the parent archetype, each containing an instance of this archetype, when there are clinically significant differences such as tumour type, size, or severity in each lung.
The 'Alternative structure' SLOT allows inclusion of additional archetypes that provide an alternative structure for describing the same body site, such as CLUSTER.anatomical_location_relative or CLUSTER.anatomical_location_clock, should this be required. In situations where this archetype is used to name a large or non-specific body part, the additional use of the CLUSTER.anatomical_location_relative archetype will support recording of a more precise location, for example, 2 cm anterior to the cubital fossa of the left forearm or 4 cm below the right costal margin on the chest wall in the mid-clavicular line.
If this archetype is used within other archetypes where the specified subject of care is not the individual for whom the record is being created, for example a fetus in utero, then the anatomical location will be identifying a body site on or within the fetus.
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2008-11-10
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2008-11-10
- 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
- References: Anatomy Mapper website [Internet]. Matt Molenda, [cited 2015 Apr 27]. Available from: http://www.anatomymapper.com/.
- Current Contact: Heather Leslie, Atomica Informatics, heather.leslie@atomicainformatics.com
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: 235D9CDE069C2AEF58B46A00190C05F8
- Build Uid: 55df31f4-72ab-49d6-a014-3693d1a57acd
- 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 https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.
- Revision: 1.4.0
This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If 'Body site name' is already identified in an archetype in which this Anatomical location archetype has been nested, then this data element may be redundant. However, it might be reasonable to duplicate 'Body site name' in this archetype to support semantic querying using this archetype, instead of the archetype in which it has been nested.
Use to increase precision of identification of the body site, if required. For example, the upper right quadrant or McBurney's point on the abdominal wall or interphalangeal joint of the great toe. If the 'Body site name' data element uses pre-coordinated terms that include the specific site, then this data element is redundant. In most situations this will be a single specific site. This data element has multiple occurrences to support less common use cases which need to identify a single anatomical location involving two or more adjacent and continuous specific sites. For example, to describe the specific site of a single tumour extending across the 2nd, 3rd and 4th ribs.
If the 'Body site name' includes a pre-coordinated term that already specifies laterality, this data element may be redundant. If the findings require documentation of a body site on both the left and right sides of the body, or involving both sides of a paired structure or region, use 'Left and right' only when the same anatomical site is affected on both sides and side-specific detail is not required. If the findings differ significantly between sides, each should be recorded as a separate instance of this archetype with the appropriate laterality.
- Left [Left side of the body.]
[SNOMED-CT::7771000 | Left] - Right [Right side of the body.]
[SNOMED-CT::24028007 | Right] - Left and right [Both the left and right sides of the body, or involving both sides of a paired organ, body structure, or anatomical region.]
[SNOMED-CT::51440002 | Right and left]
Use to increase precision of identification of the body site, if required. Common aspects have been included as a value set, which can be extended over time, plus a free text option. Assumes that the body is being described while in the anatomical position. For example: proximal urethra; plantar aspect of the left thumb. Multiple aspects can also be described, if required, by allowing for 0..2 occurrences. For example: a lesion may be on the left anterior/lateral (ie anterolateral) chest wall. If the 'Body site name' data element uses pre-coordinated terms that include the aspect, then this data element is redundant.
Choice of:
Coded Text- Medial [Towards the midline of the body site.]
- Lateral [Towards the side, or edge, of the body site.]
- Superior [Above the body site, often meaning towards the head.]
- Inferior [Below the body site, often meaning towards the feet.]
- Anterior [Towards the front, or ventral surface, of the body site.]
- Posterior [Towards the back, or dorsal surface, of the body site.]
- Proximal [More central or closer to the point of attachment, and usually describing part of a limb, digit or appendage.]
- Distal [More peripheral, or further from the point of attachment, and usually describing part of a limb, digit or appendage.]
- Deep [Away from the surface of the body site.]
- Superficial [Towards the surface of the body site.]
- Palmar [Towards the palm of the hand.]
- Plantar [Towards the sole of the foot.]
- Dorsal [Towards the back of the hand or top of the foot. To be used as opposites of palmar or plantar, not as a synonym of posterior.]
- Mid [In the middle of the body site.]
- Oral [Towards the mouth. Usually used to describe locations within the digestive system.]
- Anal [Towards the anus. Usually used to describe locations within the digestive system.]
Text
Common anatomical lines have been included as a value set, which can be extended over time, plus a free text option. The additional use of this data element allows for recording of the typical position of the heart's apex beat at 5th intercostal space, left side, and mid-clavicular line. If the 'Body site name' data element uses pre-coordinated terms that include anatomical line, then this data element is redundant.
Choice of:
- Coded Text
- Midline [Line running vertically which divides the body into left and right portions, passing through the head, spinal cord, and umbilicus. Alternatively it can refer to a line dividing a body part into two equal portions, for example a digit.]
- Midaxillary line [Line running vertically down the surface of the body, passing through the apex of the axilla.]
- Anterior axillary line [Line running vertically down the surface of the body, passing through the anterior axillary skinfold.]
- Posterior axillary line [Line running vertically down the surface of the body, passing through the posterior axillary skinfold.]
- Mid-clavicular line [Line running vertically down the surface of the body, parallel to the midline and passing through the midpoint of the clavicle.]
- Mid-pupillary line [Line running vertically down the face through the midpoint of the pupil when looking directly forward.]
- Mid-scapular line [Line running vertically down the posterior surface of the body, parallel to the midline and passing through the inferior point of the scapula.]
- Text
For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area.
For example, relative location or precise locations using coordinates.
Include:
openEHR-EHR-CLUSTER.anatomical_
openEHR-EHR-CLUSTER.anatomical_
Include:
openEHR-EHR-CLUSTER.media_
Grethe Almenning, Bergen kommune, Norway
Tomas Alme, DIPS, Norway
Erling Are Hole, Helse Bergen, Norway
Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Koray Atalag, GALATA-Digital, New Zealand
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)
Maria Beate Nupen-Stieng, Oslo Universitetssykehus, Norway
Maria Beate Nupen, Oslo Universitetssykehus, Norway
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, Queensland Health, Australia
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Mona Didriksen, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain
Shahla Foozonkhah, Ocean Informatics, Australia
Einar Fosse, National Centre for Integrated Care and Telemedicine, Norway
Sebastian Garde, Ocean Health Systems, Germany
Bente Gjelsvik, Helse Bergen, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Sam Heard, Ocean, Congress, RACGP, Australia
Ingrid Heitmann, Oslo University Hospital, Norway
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Anca Heyd, DIPS ASA, Norway
Dunmail Hodkinson, Black Pear Software Ltd, UK
Lars Karlsen, DIPS ASA, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Shinji Kobayashi, NPO openEHR Japan, Japan
Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Liv Laugen, Oslo universitetssykehus, Norway (Nasjonal IKT redaktør)
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Vesna Levasic, Orthopaedic Hospital Valdoltra, Slovenia
Hallvard Lærum, Norwegian Directorate of e-health, Norway
Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway
Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Erik Nissen, Cambio Healthcare Systems AB, Sweden
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Anne Pauline Anderssen, Helse Nord RHF, Norway
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Terje Sagmyr, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Thomas Schopf, University Hospital of North-Norway, Norway
Micaela Thierley, Helse Vest IKT, Norway
Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
John Tore Valand, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Richard Townley-O'Neill, Australian Digital Health Agency, Australia
Dmitri Wall, National and International Skin Registry solutions, Ireland
- German: Sarah Ballout, Darin Leonhardt, PLRI für medizinische Informatik/ Medizinische Hochschule, ballout.sarah@mh-hannover.de, leonhardt.darin@mh-hannover.de
- Swedish: Åsa Skagerhult, Linda Aulin, Romi Shweta Pathak, Henna Haapa Hybinette, sofia Lång Janstad, Sajjad Saffari Miandoab, Region Östergötland, Region Stockholm, Karolinska universitetssjukhuset, Karolinska University Hospital, asa.skagerhult@regionostergotland.se, linda.aulin@sll.se, romi.pathak@regionstockholm.se, henna.haapa-hybinette@regionstockholm.se, sofia.lang-janstad@regionstockholm.se, sajjad.saffari-miandoab@regionstockholm.se
- Norwegian Bokmål: Lars Bitsch-Larsen, Vebjørn Arntzen, Haukeland University Hospital of Bergen, Norway, Oslo University Hospital, varntzen@ous-hf.no, MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine.
- Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP, osmeire.acsanzovo@hsl.org.br
- Arabic (Syria): Mona Saleh
- Slovenian: Biljana Princic
- French: Vanessa Pereira, Luxembourg Institute of Health (LIH), vanessapereira@protonmail.com
- Dutch: Michiel Klitsie, Nedap Healthcare, michiel.klitsie@nedap.com
- Catalan: Clara Calleja Vega, CatSalut. Servei Català de la Salut., ccalleja@catsalut.cat
Other Contributors: TRADCREA - Spanish (Spain): Clara Calleja Vega, CatSalut. Servei Català de la Salut., ccalleja@catsalut.cat