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={identities=[], other_participations=[], events=[], details=[], 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[at0005], code=at0005, itemType=SLOT, level=1, text=Additional details, description=Additional structured details about imaging findings for the identified body structure or region, or findings of related structures., 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_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: Runtime name constraint:
- at0026::Length [The measured length of the longest edge or aspect of the anomaly.]
- at0027::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.]
- at0028::Height [The measured length of the vertical aspect of the anomaly, from the base to the top.]
- at0029::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.]
- at0051::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=- 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, 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=[], 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[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[at0005], code=at0005, itemType=SLOT, level=1, text=Additional details, description=Additional structured details about imaging findings for the identified body structure or region, or findings of related structures., 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_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: Runtime name constraint:
- at0026::Length [The measured length of the longest edge or aspect of the anomaly.]
- at0027::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.]
- at0028::Height [The measured length of the vertical aspect of the anomaly, from the base to the top.]
- at0029::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.]
- at0051::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=- 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, 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] |