ARCHETYPE Imaging examination of an abnormality (openEHR-EHR-CLUSTER.imaging_exam-abnormality.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_exam-abnormality.v0
ConceptImaging examination of an abnormality
DescriptionFindings of a morphological abnormality observed in an imaging examination targeting a specified structure or region, using radiographic techniques.
UseUse to record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting a specified body structure or region. This archetype has been designed to be used in the 'Structured imaging findings' SLOT within a CLUSTER.imaging_exam archetype which will identify the structure containing the morphological abnormality, 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 'Additional details' SLOT within this archetype to record additional nested levels of structured imaging findings for related body substructures or site-specific findings.
MisuseNot to be used to record findings for a specified body structure or region. Use other archetypes from the CLUSTER.imaging_exam family 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.
PurposeTo record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting a specified body structure or region.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2021-11-24
Other Details LanguageAuthor 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=83B3A1551301595F63FACC38BB2A6A89, build_uid=3988ff9c-31b7-4a62-a321-e74bb0e6bc31, 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
Lifecyclein_development
UID699e95a0-eee5-41e4-a7d3-4d99a1a6d677
Language useden
Citeable Identifier1013.1.5907
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings of a morphological abnormality observed in an imaging examination targeting a specified structure or region, using radiographic techniques., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo University Hospital
Liv Laugen, Oslo University Hospital
Peter Fedorcsak, Oslo University Hospital, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={protocol=[], source=[], state=[], ism_transition=[], content=[], relationships=[], activities=[], description=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001.1], code=at0001.1, itemType=ELEMENT, level=1, text=Body structure, description=Identification of the body structure or region examined., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Anatomical location, description=Simple body site for the identified structure., comment=If the anatomical location of the identified body structure is known, 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[at0003], code=at0003, itemType=SLOT, level=1, text=Structured anatomical location, description=Structured details about the anatomical location of the identified body structure., comment=If the anatomical location of the identified body structure is known or it has been identified in the 'Anatomical location' data element, this data element is 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[at0005], code=at0005, itemType=SLOT, level=1, text=SLOT: Additional details, description=Additional structured details about imaging findings for the identified body structure or region, or findings for related substructures., 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.imaging_finding.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lymph_node.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lymph_node_group.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-abnormality.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Impression, description=Narrative concise, clinically relevant impression of all imaging findings for the identified body structure., comment=Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the imaging findings, not captured in other fields., 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[at0.2], code=at0.2, itemType=ELEMENT, level=1, text=Label, description=A label for the abnormality., comment=Use to differentiate one abnormality from another when there is more than one present at the same site., 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[at0.3], code=at0.3, itemType=ELEMENT, level=1, text=Type, description=The type of abnormality., comment=Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy., 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[at0.4], code=at0.4, itemType=ELEMENT, level=1, text=Diameter, description=A measured diameter of the abnormality., comment=This data element has 3 occurrences to allow for 3 measurements in different axes., uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • >=0.0 mm
    Limit decimal places: 0
  • >=0.0 cm
    Limit decimal places: 1
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.9], code=at0.9, itemType=ELEMENT, level=1, text=Shape, description=The shape of the abnormality., 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[at0.10], code=at0.10, itemType=ELEMENT, level=1, text=Texture, description=The texture of the abnormality., 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[at0.11], code=at0.11, itemType=ELEMENT, level=1, text=Definition, description=The definition of the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  Coded Text
    • Well-defined [The abnormality is well-defined.]
    • Poorly-defined [The abnormality is poorly-defined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.14], code=at0.14, itemType=ELEMENT, level=1, text=Contour, description=The contour of the abnormality., 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[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Margin, description=The margin of the abnormality., 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[at0.16], code=at0.16, itemType=ELEMENT, level=1, text=Calcification, description=Presence of calcification in the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Calcification is observed.]
  • Absent [Calcification is not observed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Effect, description=Narrative description about the effect of the abnormality on surrounding structures., comment=For example: 'pressing on blood vessel'., 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[at0.20], code=at0.20, itemType=ELEMENT, level=1, text=Vascularisation, description=Assessment of the blood flow to the abnormality., comment=Often determined by colour doppler or similar., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  Coded Text
    • None [No blood flow can be detected.]
    • Mild [Minimal blood flow can be detected.]
    • Moderate [Moderate blood flow can be detected.]
    • Marked [Marked blood flow can be detected.]
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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[at0005], code=at0005, itemType=SLOT, level=1, text=SLOT: Additional details, description=Additional structured details about imaging findings for the identified body structure or region, or findings for related substructures., 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.imaging_finding.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lymph_node.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lymph_node_group.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-abnormality.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Impression, description=Narrative concise, clinically relevant impression of all imaging findings for the identified body structure., comment=Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the imaging findings, not captured in other fields., 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[at0.2], code=at0.2, itemType=ELEMENT, level=1, text=Label, description=A label for the abnormality., comment=Use to differentiate one abnormality from another when there is more than one present at the same site., 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[at0.3], code=at0.3, itemType=ELEMENT, level=1, text=Type, description=The type of abnormality., comment=Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy., 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[at0.4], code=at0.4, itemType=ELEMENT, level=1, text=Diameter, description=A measured diameter of the abnormality., comment=This data element has 3 occurrences to allow for 3 measurements in different axes., uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • >=0.0 mm
    Limit decimal places: 0
  • >=0.0 cm
    Limit decimal places: 1
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.9], code=at0.9, itemType=ELEMENT, level=1, text=Shape, description=The shape of the abnormality., 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[at0.10], code=at0.10, itemType=ELEMENT, level=1, text=Texture, description=The texture of the abnormality., 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[at0.11], code=at0.11, itemType=ELEMENT, level=1, text=Definition, description=The definition of the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  Coded Text
    • Well-defined [The abnormality is well-defined.]
    • Poorly-defined [The abnormality is poorly-defined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.14], code=at0.14, itemType=ELEMENT, level=1, text=Contour, description=The contour of the abnormality., 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[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Margin, description=The margin of the abnormality., 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[at0.16], code=at0.16, itemType=ELEMENT, level=1, text=Calcification, description=Presence of calcification in the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present [Calcification is observed.]
  • Absent [Calcification is not observed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Effect, description=Narrative description about the effect of the abnormality on surrounding structures., comment=For example: 'pressing on blood vessel'., 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[at0.20], code=at0.20, itemType=ELEMENT, level=1, text=Vascularisation, description=Assessment of the blood flow to the abnormality., comment=Often determined by colour doppler or similar., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  Coded Text
    • None [No blood flow can be detected.]
    • Mild [Minimal blood flow can be detected.]
    • Moderate [Moderate blood flow can be detected.]
    • Marked [Marked blood flow can be detected.]
, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]