ARCHETYPE Imaging examination of the uterus (openEHR-EHR-CLUSTER.imaging_exam-uterus.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_exam-uterus.v0
ConceptImaging examination of the uterus
DescriptionFindings on radiological examination of the uterus.
UseUse to record the findings on radiological examination of the uterus, and their interpretation. The intended scope for this archetype is to eventually record all detailed findings on radiological examination of the uterus using any modality. It is anticipated that further data elements may be added as requirements are identified and confirmed. This archetype is designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result, 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 appropriate SLOTs: - Details about the imaging examination of one or more gestations will be recorded using the 'Pregnancy findings' SLOT; - Details about the imaging examination of the uterine cervix will be recorded within the 'Cervical findings' SLOT; - Details about the imaging examination an intrauterine device (IUD) will be recorded within the 'IUD findings' SLOT; and - Details about other imaging findings such as structural abnormalities or lesions will be recorded using the 'Additional findings' SLOT.
MisuseNot to be used to record imaging examination findings for any body structure or region other than the uterus. 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 the findings on radiological examination of the uterus, and their interpretation.
ReferencesAbuhamad A, Chaoui R, Jeanty P, Paladini D, Walsh E. Ultrasound in Obstetrics and Gynecology: A Practical Approach [Internet]. The Global Library of Women’s Medicine; 2014 [cited 2021 Dec 21]. 322 p. Available from: https://www.glowm.com/pdf/Ultrasound_in_obstetrics_and_gynecology-chapter11.pdf.

AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Female Pelvis. J Ultrasound Med. 2020 May;39(5):E17-E23. doi: 10.1002/jum.15205. Epub 2020 Mar 9. PMID: 32150295. Available from: https://www.aium.org/resources/guidelines/femalePelvis.pdf.

American Institute of Ultrasound in Medicine; Society for Reproductive Endocrinology and Infertility; American Society of Reproductive Medicine. AIUM practice guideline for ultrasonography in reproductive medicine. J Ultrasound Med. 2009 Jan;28(1):128-37. PMID: 19106372. Available from: https://www.aium.org/resources/guidelines/reproductiveMed.pdf.

Leone FP, Timmerman D, Bourne T, Valentin L, Epstein E, Goldstein SR, Marret H, Parsons AK, Gull B, Istre O, Sepulveda W, Ferrazzi E, Van den Bosch T. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol. 2010 Jan;35(1):103-12. doi: 10.1002/uog.7487. PMID: 20014360. Available from: https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.7487.
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, references=Abuhamad A, Chaoui R, Jeanty P, Paladini D, Walsh E. Ultrasound in Obstetrics and Gynecology: A Practical Approach [Internet]. The Global Library of Women’s Medicine; 2014 [cited 2021 Dec 21]. 322 p. Available from: https://www.glowm.com/pdf/Ultrasound_in_obstetrics_and_gynecology-chapter11.pdf. AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Female Pelvis. J Ultrasound Med. 2020 May;39(5):E17-E23. doi: 10.1002/jum.15205. Epub 2020 Mar 9. PMID: 32150295. Available from: https://www.aium.org/resources/guidelines/femalePelvis.pdf. American Institute of Ultrasound in Medicine; Society for Reproductive Endocrinology and Infertility; American Society of Reproductive Medicine. AIUM practice guideline for ultrasonography in reproductive medicine. J Ultrasound Med. 2009 Jan;28(1):128-37. PMID: 19106372. Available from: https://www.aium.org/resources/guidelines/reproductiveMed.pdf. Leone FP, Timmerman D, Bourne T, Valentin L, Epstein E, Goldstein SR, Marret H, Parsons AK, Gull B, Istre O, Sepulveda W, Ferrazzi E, Van den Bosch T. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol. 2010 Jan;35(1):103-12. doi: 10.1002/uog.7487. PMID: 20014360. Available from: https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.7487., original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=4E74AC49056CDB46722308BF3C171A4C, build_uid=dc0ed4ad-032b-4a64-8cca-be039732021d, 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}
Keywordsuterus, fundus, myometrium, endometrium, junction
Lifecyclein_development
UIDbc440ac0-0176-4f2c-9e3e-0351d9f07354
Language useden
Citeable Identifier1013.1.5914
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings on radiological examination of the uterus., archetypeConceptComment=null, otherContributors=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
Peter Fedorcsak, University of Oslo, Norway (openEHR Editor)
Heather Grain, Llewelyn Grain Informatics, Australia
Evelyn Hovenga, EJSH Consulting, Australia
Anjali Kulkarni, Karkinos, India
Liv Laugen, ​Oslo University Hospital, Norway, Norway (openEHR Editor)
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Arunakiry Natarajan, medondo, Germany
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Natalia Strauch, Medizinische Hochschule Hannover, Germany
Norwegian Review Summary, Norwegian Public Hospitals, Norway, originalLanguage=en, translators=German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
Norwegian Bokmål: Peter Fedorcsak, Vebjørn Arntzen, Marit Alice Venheim, University of Oslo, Oslo University Hospital, Helse Vest IKT, peterfe@uio.no, varntzen@ous-hf.no, marit.alice.venheim@helse-vest-ikt.no
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={other_participations=[], provider=[], ism_transition=[], events=[], 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=If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT becomes redundant., 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=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_group.v0 and specialisations or
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openEHR-EHR-CLUSTER.imaging_exam-lesion.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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the imaging findings of the body structure, 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[at0.13], code=at0.13, itemType=ELEMENT, level=1, text=Length, description=The length of the entire uterus., comment=Usually measured in the midsagittal plane, from the outer serosal surface of the fundus to the external os of the cervix., uncommonOntologyItems=null, occurencesFormal=0..1, 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[at0.45], code=at0.45, itemType=ELEMENT, level=1, text=Body length, description=The length of the body of the uterus., comment=Usually measured in the midsagittal plane, from the outer serosal surface of the fundus to the internal os of the cervix., uncommonOntologyItems=null, occurencesFormal=0..1, 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[at0.14], code=at0.14, itemType=ELEMENT, level=1, text=Width, description=The width of the uterus., comment=Usually measured at the widest dimension in the transverse or coronal plane, perpendicular to the length., uncommonOntologyItems=null, occurencesFormal=0..1, 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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Height (AP), description=The anteroposterior height of the uterus., comment=Usually measured in the midsagittal plane anteroposteriorly from outer to outer serosal surfaces. , uncommonOntologyItems=null, occurencesFormal=0..1, 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[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=Uterine version, description=The relation between uterus and the vagina in the sagittal plane., comment=Also known as 'position'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anteverted [The uterus is angled forward relative to the vagina.]
  • Neutral [The uterus and the vagina are in the same plane.]
  • Retroverted [The uterus is angled backward relative to the vagina.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.29], code=at0.29, itemType=ELEMENT, level=1, text=Uterine flexion, description=The relation between uterine body and the cervix in the sagittal plane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anteflexed [The cervix-body angle faces anteriorly.]
  • Retroflexed [The cervix-body angle faces posteriorly.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.16], code=at0.16, itemType=ELEMENT, level=1, text=Endometrium description, description=Narrative description about the endometrium., comment=For example: focal abnormalities, endometrial midline, vasularisation, and fluid or masses in the cavity. Record structured details about any lesion using the CLUSTER.imaging_exam-lesion and related specialisations nested within the 'Additional details' SLOT., 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[at0.17], code=at0.17, itemType=ELEMENT, level=1, text=Endometrial thickness, description=Maximal measured thickness of the endometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units: >=0.0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.52], code=at0.52, itemType=ELEMENT, level=1, text=Endometrial homogeneity, description=Description about the endometrial homogeneity., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Homogeneous [The echotexture of the endometrium is uniform.]
  • Heterogeneous [The echotexture of the endometrium is not uniform.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.18], code=at0.18, itemType=ELEMENT, level=1, text=Endometrial echogenicity, description=Description about the endometrial echogenicity compared with the echogenicity of the myometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Hyperechoic [Increased echogenicity of the endometrium, compared to the myometrium.]
  • Isoechoic [Similar echogenicity of the endometrium, compared to the myometrium.]
  • Trilaminar [A triple line pattern of the endometrium is observed.]
  • Hypoechoic [Decreased echogenicity of the endometrium, compared to the myometrium.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.55], code=at0.55, itemType=ELEMENT, level=1, text=Endometrial uniformity, description=Description about the homogeneity and symmetry of the endometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Uniform [Endometrium appears homogeous with symmetrical anterior and posterior sides. It may also include the three-layer pattern.]
  • Non-uniform [Endometrium appears heterogenous with asymmetrical anterior and posterior sides and cysts.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.58], code=at0.58, itemType=ELEMENT, level=1, text=Endometrial midline, description=Description about the interface between the opposing surfaces of the two endometrial walls., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Linear [A straight hyperechogenic interface within the endometrium is observed.]
  • Non-linear [A wavy hyperechogenic interface within the endometrium is observed.]
  • Irregular [An irregular or interrupted hyperechogenic interface within the endometrium is observed.]
  • Not defined [The absence of a hyperechogenic interface within the endometrium is observed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.24], code=at0.24, itemType=ELEMENT, level=1, text=Junctional zone, description=Description about the junctional zone between the endometrium and the myometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular [The junctional zone appears regular.]
  • Irregular [The junctional zone appears irregular.]
  • Interrupted [The junctional zone appears interrupted.]
  • Not defined [The junctional zone is not visible or well defined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.37], code=at0.37, itemType=ELEMENT, level=1, text=Junctional zone thickness, description=Measured thickness of the junctional zone., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units: >=0.0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Myometrium description, description=Narrative description about the myometrium., comment=For example: contour changes, texture, masses, and cysts as well as symmetry between the anterior and posterior segments of the myometrium. Record structured details about any morphological abnormality using CLUSTER.imaging_exam-lesion nested within the 'Additional details' SLOT., 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[at0.46], code=at0.46, itemType=SLOT, level=1, text=Cervical findings, description=Additional structured details about imaging findings about examination of the uterine cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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  • Present [Evidence of one or more intrauterine pregnancies are observed - gestational sac, embryo or foetus.]
  • Absent [No intrauterine pregnancy is observed.]
  • Indeterminate [It is not possible to determine if an intrauterine pregnancy is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.47], code=at0.47, itemType=SLOT, level=1, text=Pregnancy findings, description=Additional structured details about imaging findings about one or more intrauterine pregnancies., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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  • Present [An IUD is observed in the uterus.]
  • Absent [No IUD is observed in the uterus.]
  • Indeterminate [It is not possible to determine if an IUD is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.48], code=at0.48, itemType=SLOT, level=1, text=IUD findings, description=Structured details about imaging findings for an intrauterine device., comment=For example: to carry the location of the IUD *within the uterus* only; or details about the IUD device. If an IUD is located outside of the uterus, the IUD details should be recorded within the imaging archetype relevant for region or structure in which the IUD is located., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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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=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_group.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lesion-adnexal_mass.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lesion.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[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the imaging findings of the body structure, 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[at0.13], code=at0.13, itemType=ELEMENT, level=1, text=Length, description=The length of the entire uterus., comment=Usually measured in the midsagittal plane, from the outer serosal surface of the fundus to the external os of the cervix., uncommonOntologyItems=null, occurencesFormal=0..1, 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[at0.45], code=at0.45, itemType=ELEMENT, level=1, text=Body length, description=The length of the body of the uterus., comment=Usually measured in the midsagittal plane, from the outer serosal surface of the fundus to the internal os of the cervix., uncommonOntologyItems=null, occurencesFormal=0..1, 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[at0.14], code=at0.14, itemType=ELEMENT, level=1, text=Width, description=The width of the uterus., comment=Usually measured at the widest dimension in the transverse or coronal plane, perpendicular to the length., uncommonOntologyItems=null, occurencesFormal=0..1, 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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Height (AP), description=The anteroposterior height of the uterus., comment=Usually measured in the midsagittal plane anteroposteriorly from outer to outer serosal surfaces. , uncommonOntologyItems=null, occurencesFormal=0..1, 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[at0.25], code=at0.25, itemType=ELEMENT, level=1, text=Uterine version, description=The relation between uterus and the vagina in the sagittal plane., comment=Also known as 'position'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anteverted [The uterus is angled forward relative to the vagina.]
  • Neutral [The uterus and the vagina are in the same plane.]
  • Retroverted [The uterus is angled backward relative to the vagina.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.29], code=at0.29, itemType=ELEMENT, level=1, text=Uterine flexion, description=The relation between uterine body and the cervix in the sagittal plane., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anteflexed [The cervix-body angle faces anteriorly.]
  • Retroflexed [The cervix-body angle faces posteriorly.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.16], code=at0.16, itemType=ELEMENT, level=1, text=Endometrium description, description=Narrative description about the endometrium., comment=For example: focal abnormalities, endometrial midline, vasularisation, and fluid or masses in the cavity. Record structured details about any lesion using the CLUSTER.imaging_exam-lesion and related specialisations nested within the 'Additional details' SLOT., 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[at0.17], code=at0.17, itemType=ELEMENT, level=1, text=Endometrial thickness, description=Maximal measured thickness of the endometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units: >=0.0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.52], code=at0.52, itemType=ELEMENT, level=1, text=Endometrial homogeneity, description=Description about the endometrial homogeneity., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Homogeneous [The echotexture of the endometrium is uniform.]
  • Heterogeneous [The echotexture of the endometrium is not uniform.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.18], code=at0.18, itemType=ELEMENT, level=1, text=Endometrial echogenicity, description=Description about the endometrial echogenicity compared with the echogenicity of the myometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Hyperechoic [Increased echogenicity of the endometrium, compared to the myometrium.]
  • Isoechoic [Similar echogenicity of the endometrium, compared to the myometrium.]
  • Trilaminar [A triple line pattern of the endometrium is observed.]
  • Hypoechoic [Decreased echogenicity of the endometrium, compared to the myometrium.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.55], code=at0.55, itemType=ELEMENT, level=1, text=Endometrial uniformity, description=Description about the homogeneity and symmetry of the endometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Uniform [Endometrium appears homogeous with symmetrical anterior and posterior sides. It may also include the three-layer pattern.]
  • Non-uniform [Endometrium appears heterogenous with asymmetrical anterior and posterior sides and cysts.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.58], code=at0.58, itemType=ELEMENT, level=1, text=Endometrial midline, description=Description about the interface between the opposing surfaces of the two endometrial walls., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Linear [A straight hyperechogenic interface within the endometrium is observed.]
  • Non-linear [A wavy hyperechogenic interface within the endometrium is observed.]
  • Irregular [An irregular or interrupted hyperechogenic interface within the endometrium is observed.]
  • Not defined [The absence of a hyperechogenic interface within the endometrium is observed.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.24], code=at0.24, itemType=ELEMENT, level=1, text=Junctional zone, description=Description about the junctional zone between the endometrium and the myometrium., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular [The junctional zone appears regular.]
  • Irregular [The junctional zone appears irregular.]
  • Interrupted [The junctional zone appears interrupted.]
  • Not defined [The junctional zone is not visible or well defined.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.37], code=at0.37, itemType=ELEMENT, level=1, text=Junctional zone thickness, description=Measured thickness of the junctional zone., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units: >=0.0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.19], code=at0.19, itemType=ELEMENT, level=1, text=Myometrium description, description=Narrative description about the myometrium., comment=For example: contour changes, texture, masses, and cysts as well as symmetry between the anterior and posterior segments of the myometrium. Record structured details about any morphological abnormality using CLUSTER.imaging_exam-lesion nested within the 'Additional details' SLOT., 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[at0.46], code=at0.46, itemType=SLOT, level=1, text=Cervical findings, description=Additional structured details about imaging findings about examination of the uterine cervix., 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-cervix.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.5], code=at0.5, itemType=ELEMENT, level=1, text=Pregnancy presence, description=The presence or absence of an intrauterine pregnancy., 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 [Evidence of one or more intrauterine pregnancies are observed - gestational sac, embryo or foetus.]
  • Absent [No intrauterine pregnancy is observed.]
  • Indeterminate [It is not possible to determine if an intrauterine pregnancy is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.47], code=at0.47, itemType=SLOT, level=1, text=Pregnancy findings, description=Additional structured details about imaging findings about one or more intrauterine pregnancies., 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-foetus.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-pregnant_uterus.v0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.32], code=at0.32, itemType=ELEMENT, level=1, text=IUD presence, description=The presence or absence of an intrauterine device., 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 [An IUD is observed in the uterus.]
  • Absent [No IUD is observed in the uterus.]
  • Indeterminate [It is not possible to determine if an IUD is present or absent.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.48], code=at0.48, itemType=SLOT, level=1, text=IUD findings, description=Structured details about imaging findings for an intrauterine device., comment=For example: to carry the location of the IUD *within the uterus* only; or details about the IUD device. If an IUD is located outside of the uterus, the IUD details should be recorded within the imaging archetype relevant for region or structure in which the IUD is located., 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.device.v1 and specialisations, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]