ARCHETYPE ID | openEHR-EHR-CLUSTER.anatomical_location.v1 |
Concept | Anatomical location |
Description | A physical site on or within the human body. |
Use | Use to record structured and consistent details about a single identified physical site on, or within, the human body. This archetype is specifically designed to be used within the context of any appropriate ENTRY or CLUSTER archetypes which supply the context of the anatomical location. As a fundamental part of clinical practice, clinicians can describe anatomical locations in a myriad of complex and variable ways. In practice, some archetypes carry a single data element for carrying a simple description of body site - for example, OBSERVATION.blood_pressure and CLUSTER.symptom when describing ear pain. In this situation, where the value set is predictable and simple to define, this single data element is a very accurate and pragmatic way to record the site in the body and to query at a later date. However in the situation where the anatomical location is not well defined or needs to be determined at run-time, it may be more flexible to use this structured archetype. For example, in the situation where any symptom can be recorded without any predefined scope of the type of symptom, then allowing the use of this archetype to specifically define an anatomical location in the body may be useful. In this case the CLUSTER.symptom archetype also carries a SLOT for 'Detailed anatomical location' which can include this archetype to support maximal flexibility in recording anatomical location data. This archetype supports recording complex structured anatomical sites. For example, the apex beat of the heart is typically found at the fifth left intercostal space in the mid-clavicular line, tenderness at McBurney's point on the abdominal wall or a laceration on the palmar aspect of the proximal right thumb. A combination of the data elements in this archetype can be used to individually record each component of a postcoordinated terminology expression that represents the anatomical site. 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 the situation where this archetype can only be used to name a large and/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 R 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. |
Misuse | Not to be used for specifiying unilateral/bilateral occurrences of an anatomical feature. |
Purpose | To identify and record structured details about a single physical site on, or within, the human body using macroscopic anatomical terms. |
References | Anatomy Mapper website [Internet]. Matt Molenda, [cited 2015 Apr 27]. Available from: http://www.anatomymapper.com/. |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2008-11-10 |
Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2008-11-10 |
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, references=Anatomy Mapper website [Internet]. Matt Molenda, [cited 2015 Apr 27]. Available from: http://www.anatomymapper.com/., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=12CEE2FA9FD1CD14585E03BD0418C2BA, build_uid=5bc8a336-ce22-49a4-8300-861dbf68be5d, revision=1.1.0} |
Keywords | location, site, anatomical, anatomic region, topographic anatomy, macroscopic, anatomic, anatomy |
Lifecycle | published |
UID | 2fe9e9f8-adfd-4406-878a-82b38ef498a9 |
Language used | en |
Citeable Identifier | 1013.1.587 |
Revision | 18 |
Revision Number | 1.1.0 |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A physical site on or within the human body., archetypeConceptComment=null, otherContributors=Grethe Almenning, Bergen kommune, Norway Tomas Alme, DIPS, Norway Anne Pauline Anderssen, Helse Nord RHF, Norway Vebjørn Arntzen, Oslo universitetssykehus HF, Norway Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Helse Bergen HF, Norway (Nasjonal IKT redaktør) Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway Rong Chen, Cambio Healthcare Systems, Sweden Stephen Chu, Queensland Health, Australia Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Aitor Eguzkitza, UPNA (Public University of Navarre) - CHN (Complejo Hospitalario de Navarra), Spain Shahla Foozonkhah, Ocean Informatics, Australia Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway Sebastian Garde, Ocean Informatics, Germany Bente Gjelsvik, Helse Bergen, Norway Heather Grain, Llewelyn Grain Informatics, Australia Sam Heard, Ocean Informatics, Australia Ingrid Heitmann, NTNU, Norway Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway Anca Heyd, DIPS ASA, Norway Dunmail Hodkinson, Black Pear Software Ltd, UK Erling Are Hole, Helse Bergen, Norway Lars Karlsen, DIPS ASA, Norway Lars Morgan Karlsen, DIPS ASA, Norway Shinji Kobayashi, Kyoto University, Japan Sabine Leh, Helse-Bergen, Norway Heather Leslie, Ocean Informatics, Australia (openEHR Editor) Vesna Levasic, Orthopaedic Hospital Valdoltra, Slovenia Hallvard Lærum, Oslo Universitetssykehus HF, Norway Luis Marco Ruiz, Norwegian Center for Integrated Care and Telemedicine, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Erik Nissen, Cambio Healthcare Systems AB, Sweden Maria Beate Nupen, Oslo Universitetssykehus, Norway Bjørn Næss, DIPS ASA, Norway Andrej Orel, Marand d.o.o., Slovenia Rune Pedersen, Universitetssykehuset i Nord Norge, Norway Jussara Rotzsch, UNB, Brazil Thomas Schopf, University Hospital of North-Norway, Norway Nils Thomas Songstad, UNN HF, BUK, Barneavdelingen., Norway Micaela Thierley, Helse Bergen, Norway Rowan Thomas, St. Vincent's Hospital Melbourne, Australia Richard Townley-O'Neill, NEHTA, Australia John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) Dmitri Wall, Irish Skin Foundation, Ireland, originalLanguage=en, translators=
openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null]], description=[], context=[], activities=[], identities=[], capabilities=[], provider=[], protocol=[], content=[], source=[], credentials=[], events=[], data=[], contacts=[], ism_transition=[], details=[], relationships=[], state=[], target=[], other_participations=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, 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], code=at0001, itemType=ELEMENT, level=1, text=Body site name, description=Identification of a single physical site either on, or within, the human body., comment=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 the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0065], code=at0065, itemType=ELEMENT, level=1, text=Specific site, description=Additional detail using a specific region or a point on, or within, the identified body site., comment=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., 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[at0002], code=at0002, itemType=ELEMENT, level=1, text=Laterality, description=The side of the body on which the identified body site is located., comment=If the identified body site has no laterality, this data element should not have a value. If the 'Body site name' data element uses pre-coordinated terms that include laterality, then this data element is redundant., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=[SNOMED-CT:
openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.anatomical_ openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |