ARCHETYPE Imaging examination of an anomaly (openEHR-EHR-CLUSTER.imaging_exam_anomaly.v0)

Name: Imaging examination of an anomaly
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.imaging_exam_anomaly.v0
Concept	Imaging examination of an anomaly
Description	An incidental or ambiguous finding of an anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region.
Use	Use to record an incidental or ambiguous finding of a single anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region. If more than one anomaly has been identified within the context of the same body structure or region, use a separate instance of this archetype to describe each anomaly. The intended scope for this archetype is to record detailed findings about an anomaly using any modality. It is anticipated that specific CLUSTER archetypes will be developed in the future to record common abnormal radiological findings, such as fractures. If a specific archetype to record the anomaly is not available, use this generic archetype to record relevant findings. Until the specific archetypes are developed, current use cases include, but are not limited to: - a large, mixed solid/cystic lesion containing teeth and hair, identified within the ovary - for example, a dermoid cyst; - a solid mass identified within the right upper lobe of the lung - for example, a past infection scar or a tumour; - a calcified lesion identified within the left kidney - for example, a kidney calculus; or - a soft tissue mass identified within the heart - for example, a thrombosis. This archetype is designed to be nested within the 'Additional details' SLOT in any of the CLUSTER.imaging_exam family of archetypes which will provide the context for the anomaly, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate.
Misuse	Not to be used to record normal or abnormal findings that are expected for a specified imaging examination. Use specialised archetypes from the CLUSTER.imaging_exam family or the generic CLUSTER.imaging_exam archetype for this purpose. Not to be used to record details related to the overall findings, context or technical details related to a complete imaging examination test result. Use the OBERSERVATION.imaging_exam_result for this purpose. For example, comments on the study quality, differential diagnoses, and overall impression.
Purpose	To record an incidental or ambiguous finding of a single anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region.
References
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2021-11-24
Other Details Language	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2021-11-24
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, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=B5ECCD7560C85A5F1ED4FEEB3388A128, build_uid=fee56c3f-54f5-4fb2-9f83-f1367d9d22a0, 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=0.0.1-alpha}
Keywords	lesion, mass, tumour, tumor, nodule, cyst, calculus, thrombosus, abnormality, anomaly
Lifecycle	in_development
UID	4850bc1a-b1bb-4eda-8390-776f77690ebb
Language used	en
Citeable Identifier	1013.1.5907
Revision Number	0.0.1-alpha
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=An incidental or ambiguous finding of an anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region., archetypeConceptComment=For example: a cyst or mass; a thrombosis; a polyp; a calculus or a foreign body., otherContributors=Andreas Abildgaard, OUS, Norway Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor) SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India Jesper Blomquist, Haraldsplass Diakonale Sykehus, Norway Randi Brendberg, Helse Nord RHF, Norway Gunn Elin Blakkisrud, DIPS ASA, Norway Peter Fedorcsak, University of Oslo, Norway (openEHR Editor) Kåre Flø, DIPS ASA, Norway Heather Grain, Llewelyn Grain Informatics, Australia Johan Gustav Bellika, Norwegian Centre for Integrated Care and Telemedicine, Norway Anca Heyd, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør) Anjali Kulkarni, Karkinos, India Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Liv Laugen, Oslo University Hospital, Norway, Norway (openEHR Editor) Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør) Arunakiry Natarajan, medondo, Germany Svenne Naumann, Finnmarkssykehuset, Norway Mikael Nyström, Cambio Healthcare Systems AB, Sweden Bjørn Næss, DIPS ASA, Norway Andre Smitt-Ingebretsen, Sørlandet sykehus HF, Norway Natalia Strauch, Medizinische Hochschule Hannover, Germany Norwegian Review Summary, Norwegian Public Hospitals, Norway John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør), originalLanguage=en, translators= German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de Norwegian Bokmål: Peter Fedorcsak, Vebjørn Arntzen, University of Oslo, Oslo University Hospital, peterfe@uio.no, varntzen@ous-hf.no , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={activities=[], provider=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Body site, description=Identification of the area of the body under examination., comment=For example: a lymph node group (body structure) which found in the 'Right axilla'. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable. If the body site has been fully identified in the 'Body structure' 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[at0003], code=at0003, itemType=SLOT, level=1, text=Structured body site, description=Structured details about the area of the body under examination., comment=For example: details about a relative anatomical location, such as '2cm distal to the appendix'. If the body site has been fully identified in the 'Body structure' or 'Body site' data elements, then 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_relative.v2 and specialisations or openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=ELEMENT, level=1, text=Imaging findings, description=Narrative description of the imaging findings observed during this 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[at0006], code=at0006, itemType=ELEMENT, level=1, text=Impression, description=Single word, phrase or brief description that represents the clinical meaning and significance of all imaging findings for the identified body structure., comment=Also referred to as 'Interpretation' or 'Opinion'. For example: 'No abnormality detected' or 'Free fluid present'. Coding of the 'Impression' with a terminology is permitted, if useful. Multiple occurrences allow for more than one coded impression. 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values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0041], code=at0041, itemType=ELEMENT, level=1, text=Calcification, description=Presence of calcification in the anomaly., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0017::Present [Calcification is present.] at0018::Absent [Calcification is not present.] at0032::Indeterminate [It is not possible to determine if calcification is present or absent.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0042], code=at0042, itemType=ELEMENT, level=1, text=Calcification description, description=Description about the pattern of calcification observed., comment=The pattern of calcification can be coded if desired., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, 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