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=- 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, Haukeland University Hospital of Bergen, Norway, 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
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], events=[], details=[], provider=[], items=[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::272741003 | Laterality], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0064], code=at0064, itemType=ELEMENT, level=1, text=Aspect, description=Qualifying detail about the specific aspect of the identified body site., comment=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., uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
- Coded Text
- at0067::Medial [Towards the midline of the body site.]
- at0068::Lateral [Towards the side, or edge, of the body site.]
- at0069::Superior [Above the body site, often meaning towards the head.]
- at0070::Inferior [Below the body site, often meaning towards the feet.]
- at0071::Anterior [Towards the front, or ventral surface, of the body site.]
- at0072::Posterior [Towards the back, or dorsal surface, of the body site.]
- at0073::Proximal [More central or closer to the point of attachment, and usually describing part of a limb, digit or appendage.]
- at0074::Distal [More peripheral, or further from the point of attachment, and usually describing part of a limb, digit or appendage.]
- at0080::Deep [Away from the surface of the body site.]
- at0081::Superficial [Towards the surface of the body site.]
- at0075::Palmar [Towards the palm of the hand.]
- at0076::Plantar [Towards the sole of the foot.]
- at0082::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.]
- at0077::Mid [In the middle of the body site.]
- at0078::Oral [Towards the mouth. Usually used to describe locations within the digestive system.]
- at0079::Anal [Towards the anus. Usually used to describe locations within the digestive system.]
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0055], code=at0055, itemType=ELEMENT, level=1, text=Anatomical Line, description=Additional detail using theoretical lines drawn through anatomical structures used to provide a consistent reference point on the human body., comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
- Coded Text
- at0062::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.]
- at0056::Midaxillary line [Line running vertically down the surface of the body, passing through the apex of the axilla.]
- at0057::Anterior axillary line [Line running vertically down the surface of the body, passing through the anterior axillary skinfold.]
- at0058::Posterior axillary line [Line running vertically down the surface of the body, passing through the posterior axillary skinfold.]
- at0059::Mid-clavicular line [Line running vertically down the surface of the body, parallel to the midline and passing through the midpoint of the clavicle.]
- at0060::Mid-pupillary line [Line running vertically down the face through the midpoint of the pupil when looking directly forward.]
- at0063::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
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=ELEMENT, level=1, text=Description, description=Narrative description that can be used to further refine and support the 'Body site name'., comment=For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area., 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[at0053], code=at0053, itemType=SLOT, level=1, text=Alternative structure, description=Additional detail about the anatomical site using alternative approaches to describe the same body site., comment=For example, relative location or precise locations using coordinates. , 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_relative.v1 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054], code=at0054, itemType=SLOT, level=1, text=Multimedia representation, description=Image or other media used to support identification of the body site., 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, extendedValues=null]], description=[], protocol=[], ism_transition=[], context=[], data=[], activities=[], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, 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= (Cardinality: 1..*, unordered), 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::272741003 | Laterality], values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0064], code=at0064, itemType=ELEMENT, level=1, text=Aspect, description=Qualifying detail about the specific aspect of the identified body site., comment=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., uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
- Coded Text
- at0067::Medial [Towards the midline of the body site.]
- at0068::Lateral [Towards the side, or edge, of the body site.]
- at0069::Superior [Above the body site, often meaning towards the head.]
- at0070::Inferior [Below the body site, often meaning towards the feet.]
- at0071::Anterior [Towards the front, or ventral surface, of the body site.]
- at0072::Posterior [Towards the back, or dorsal surface, of the body site.]
- at0073::Proximal [More central or closer to the point of attachment, and usually describing part of a limb, digit or appendage.]
- at0074::Distal [More peripheral, or further from the point of attachment, and usually describing part of a limb, digit or appendage.]
- at0080::Deep [Away from the surface of the body site.]
- at0081::Superficial [Towards the surface of the body site.]
- at0075::Palmar [Towards the palm of the hand.]
- at0076::Plantar [Towards the sole of the foot.]
- at0082::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.]
- at0077::Mid [In the middle of the body site.]
- at0078::Oral [Towards the mouth. Usually used to describe locations within the digestive system.]
- at0079::Anal [Towards the anus. Usually used to describe locations within the digestive system.]
- Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0055], code=at0055, itemType=ELEMENT, level=1, text=Anatomical Line, description=Additional detail using theoretical lines drawn through anatomical structures used to provide a consistent reference point on the human body., comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
- Coded Text
- at0062::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.]
- at0056::Midaxillary line [Line running vertically down the surface of the body, passing through the apex of the axilla.]
- at0057::Anterior axillary line [Line running vertically down the surface of the body, passing through the anterior axillary skinfold.]
- at0058::Posterior axillary line [Line running vertically down the surface of the body, passing through the posterior axillary skinfold.]
- at0059::Mid-clavicular line [Line running vertically down the surface of the body, parallel to the midline and passing through the midpoint of the clavicle.]
- at0060::Mid-pupillary line [Line running vertically down the face through the midpoint of the pupil when looking directly forward.]
- at0063::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
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0023], code=at0023, itemType=ELEMENT, level=1, text=Description, description=Narrative description that can be used to further refine and support the 'Body site name'., comment=For example: adjacent to the vermilion border; a tattoo covers the bottom half of this area., 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[at0053], code=at0053, itemType=SLOT, level=1, text=Alternative structure, description=Additional detail about the anatomical site using alternative approaches to describe the same body site., comment=For example, relative location or precise locations using coordinates. , 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_relative.v1 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0054], code=at0054, itemType=SLOT, level=1, text=Multimedia representation, description=Image or other media used to support identification of the body site., 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, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |