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

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_exam_anomaly.v0
ConceptImaging examination of an anomaly
DescriptionAn 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.
UseUse 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.
MisuseNot 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.
PurposeTo 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
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=1F889FF8969DAC4F06D75F875EC8B756, build_uid=429dcb82-2d40-4344-a99f-0f2477bd07c7, 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}
Keywordslesion, mass, tumour, tumor, nodule, cyst, calculus, thrombosus, abnormality, anomaly
Lifecyclein_development
UID4850bc1a-b1bb-4eda-8390-776f77690ebb
Language useden
Citeable Identifier1013.1.5907
Revision Number0.0.1-alpha
AllArchetype [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
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openEHR-EHR-CLUSTER.anatomical_location_relative.v2 and specialisations or
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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-anomaly.v0 and specialisations, 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. A narrative description may include a comparison with previous studies of the identified body structure, if appropriate., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035], code=at0035, itemType=ELEMENT, level=1, text=Label, description=A label for the anomaly., comment=Use to differentiate one anomaly from another when there is more than one present within the context of the same body structure or region., 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[at0036], code=at0036, itemType=ELEMENT, level=1, text=Type, description=The type of anomaly., comment=Coding of the anomaly with an external terminology is preferred, where possible. For example, a cyst or nodule., 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[at0037], code=at0037, itemType=ELEMENT, level=1, text=(Dimension), description=A measured dimension of the anomaly., comment=This data element has unlimited occurrences to allow for measurements in 2 or more axes. If there is no clear orientation of the anomaly, for example length vs width vs height, use multiple occurrences to allow recording of the length of 2 or more axes without any specific orientation, for example 3 x 4 x 5 mm., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • >=0.0 mm
  • >=0.0 cm

Runtime name constraint:
  • Length [The measured length of the longest edge or aspect of the anomaly.]
  • Width [The measured length of widest aspect of the anomaly, usually perpendicular to the length or the measured length of the second side of two sides.]
  • Height [The measured length of the vertical aspect of the anomaly, from the base to the top.]
  • Depth [The measured length of the third aspect of the anomaly, usually perpendicular to the length and width or measurement of the vertical aspect of the anomaly from the surface to the base. May also known as thickness.]
  • Diameter [The measured length of the anomaly from edge to edge, usually of an approximately round or oval anomaly, passing through its centre.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0038], code=at0038, itemType=ELEMENT, level=1, text=Shape, description=The contour or silhouette of the anomaly., 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[at0039], code=at0039, itemType=ELEMENT, level=1, text=Texture, description=Description of the texture or consistency of the anomaly., 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[at0040], code=at0040, itemType=ELEMENT, level=1, text=Margin, description=The border of the anomaly., comment=For example: 'Well-defined' or 'Diffuse'., 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[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=
  • Present [Calcification is present.]
  • Absent [Calcification is not present.]
  • 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, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0043], code=at0043, itemType=ELEMENT, level=1, text=Effect, description=Description about the effect of the anomaly on surrounding structures., comment=For example: presence of an echo shadow behind the anomaly or that it is distorting adjacent structures., 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[at0044], code=at0044, itemType=ELEMENT, level=1, text=Vascularisation description, description=Description about the blood flow related to to the anomaly., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the imaging findings of the anomaly, 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]], 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[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
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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-anomaly.v0 and specialisations, 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. A narrative description may include a comparison with previous studies of the identified body structure, if appropriate., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035], code=at0035, itemType=ELEMENT, level=1, text=Label, description=A label for the anomaly., comment=Use to differentiate one anomaly from another when there is more than one present within the context of the same body structure or region., 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[at0036], code=at0036, itemType=ELEMENT, level=1, text=Type, description=The type of anomaly., comment=Coding of the anomaly with an external terminology is preferred, where possible. For example, a cyst or nodule., 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[at0037], code=at0037, itemType=ELEMENT, level=1, text=(Dimension), description=A measured dimension of the anomaly., comment=This data element has unlimited occurrences to allow for measurements in 2 or more axes. If there is no clear orientation of the anomaly, for example length vs width vs height, use multiple occurrences to allow recording of the length of 2 or more axes without any specific orientation, for example 3 x 4 x 5 mm., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • >=0.0 mm
  • >=0.0 cm

Runtime name constraint:
  • Length [The measured length of the longest edge or aspect of the anomaly.]
  • Width [The measured length of widest aspect of the anomaly, usually perpendicular to the length or the measured length of the second side of two sides.]
  • Height [The measured length of the vertical aspect of the anomaly, from the base to the top.]
  • Depth [The measured length of the third aspect of the anomaly, usually perpendicular to the length and width or measurement of the vertical aspect of the anomaly from the surface to the base. May also known as thickness.]
  • Diameter [The measured length of the anomaly from edge to edge, usually of an approximately round or oval anomaly, passing through its centre.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0038], code=at0038, itemType=ELEMENT, level=1, text=Shape, description=The contour or silhouette of the anomaly., 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[at0039], code=at0039, itemType=ELEMENT, level=1, text=Texture, description=Description of the texture or consistency of the anomaly., 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[at0040], code=at0040, itemType=ELEMENT, level=1, text=Margin, description=The border of the anomaly., comment=For example: 'Well-defined' or 'Diffuse'., 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[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=
  • Present [Calcification is present.]
  • Absent [Calcification is not present.]
  • 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, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0043], code=at0043, itemType=ELEMENT, level=1, text=Effect, description=Description about the effect of the anomaly on surrounding structures., comment=For example: presence of an echo shadow behind the anomaly or that it is distorting adjacent structures., 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[at0044], code=at0044, itemType=ELEMENT, level=1, text=Vascularisation description, description=Description about the blood flow related to to the anomaly., 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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the imaging findings of the anomaly, 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]], minIndents={}, termBindingRetrievalErrorMessage=null]