ARCHETYPE Imaging examination of a body structure (openEHR-EHR-CLUSTER.imaging_exam.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_exam.v1
ConceptImaging examination of a body structure
DescriptionFindings on radiological examination of a specified body structure or region.
UseUse to record the findings on radiological examination of a specified body structure or region, and their interpretation. In practice, the design intent is for the CLUSTER.imaging_exam family of archetypes to be used to record all detailed findings on radiological examination. The family of specialised archetypes are derived from this generic parent archetype, CLUSTER.imaging_exam, designed as a universal pattern for recording any findings in any specified body structure or region and using any modality. Each structure- or region-specific specialisation of this parent archetype is intended to be inclusive of all reasonably anticipated and relevant findings. For example, the CLUSTER.imaging_exam-ovary will support recording of all findings that would be expected in reporting on imaging of the ovary using any radiological modality, including the size of the ovary, largest follicle size and the diameter and description of specific follicles. Similarly, CLUSTER.imaging_exam-lymph_node_group will contain data elements required to record specific findings of a lymph node group, including its precise or relative location in the body and the number of lymph nodes in the group. If an appropriate specialisation is not available for a body structure or region, this archetype can be used to record all relevant findings related to the structure or region. This archetype and its related family of specialisations are designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result or within other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype or its specialisations need to be extended with further levels of detailed findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT.
MisuseNot to be used to record findings observed outside the identified body structure or region. Use a separate instance of one or more 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 OBSERVATION.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 a specified body structure or region, and their interpretation.
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=100080E1F9BD134B893267638A97838B, build_uid=c859c01f-6d83-4584-b571-c44413187401, revision=1.0.0}
Keywordsfinding, imaging, body, system, structure, region, observation, diagnostic, radiology, image
Lifecyclepublished
UIDba15da73-273a-4dbd-92f4-bfde28d1872c
Language useden
Citeable Identifier1013.1.5915
Revision Number1.0.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings on radiological examination of a specified body structure or region., archetypeConceptComment=null, 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
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
Evelyn Hovenga, EJSH Consulting, Australia
Kija Indrearne, Helse Bergen, Norway
Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør)
Aud Jorunn Mjelstad, Helse Bergen, Norway
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)
Svenne Naumann, Finnmarkssykehuset, Norway
Mikael Nyström, Cambio Healthcare Systems AB, Sweden
Bjørn Næss, DIPS ASA, 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: Vebjørn Arntzen, Oslo University Hospital, varntzen@ous-hf.no
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