ARCHETYPE Imaging examination of a gestational sac (openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v1)

Name: Imaging examination of a gestational sac
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v1
Concept	Imaging examination of a gestational sac
Description	Findings on radiological examination of a single gestational sac.
Use	Use to record the findings on radiological examination of a gestational sac, and their interpretation. Use a separate instance of this archetype for each gestational sac. The intended scope for this archetype is to eventually record all detailed findings on radiological examination of a gestational sac, 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 'Gestational sac findings' SLOT in the CLUSTER.imaging_exam-pregnant_uterus or the CLUSTER.imaging_exam-fallopian_tube, 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 needs to be extended with further levels of structured findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT.
Misuse	Not to be used to record imaging examination findings for any body structure or region other than a single gestational sac. Use other archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record the estimated gestational age. Use OBSERVATION.gestation 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.
Purpose	To record the findings on radiological examination of a gestational sac, and their interpretation.
References	Rodgers SK, Chang C, DeBardeleben JT, Horrow MM. Normal and Abnormal US Findings in Early First-Trimester Pregnancy: Review of the Society of Radiologists in Ultrasound 2012 Consensus Panel Recommendations. Radiographics. 2015 Nov-Dec;35(7):2135-48. doi: 10.1148/rg.2015150092. PMID: 26562242.
Copyright	© openEHR Foundation
Authors	Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2021-11-24
Other Details Language	Author 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=Rodgers SK, Chang C, DeBardeleben JT, Horrow MM. Normal and Abnormal US Findings in Early First-Trimester Pregnancy: Review of the Society of Radiologists in Ultrasound 2012 Consensus Panel Recommendations. Radiographics. 2015 Nov-Dec;35(7):2135-48. doi: 10.1148/rg.2015150092. PMID: 26562242., original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=86DC84A0A28F542F44BCB967F5AC62DD, build_uid=b9ecede7-c7b2-4a46-9715-4e81fffffdc0, revision=1.0.1}
Keywords
Lifecycle	published
UID	98134942-1ef8-4b1a-89ac-e7e28214f1b4
Language used	en
Citeable Identifier	1013.1.5941
Revision Number	1.0.1
All	Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Findings on radiological examination of a single gestational sac., 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 Randi Brendberg, Helse Nord RHF, Norway Peter Fedorcsak, University of Oslo, Norway (openEHR Editor) Heather Grain, Llewelyn Grain Informatics, Australia Anca Heyd, DIPS ASA, Norway 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) Mikael Nyström, Cambio Healthcare Systems AB, Sweden Natalia Strauch, Medizinische Hochschule Hannover, Germany Norwegian Review Summary, Norwegian Public Hospitals, Norway Ina Wille, Helse-Vest RHF, Norway, 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[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= at0.1::Gestational sac , 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.v0 and specialisations or openEHR-EHR-CLUSTER.imaging_exam-lymph_node_group.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[at0.2], code=at0.2, itemType=ELEMENT, level=1, text=Mean Sac Diameter (MSD), description=Mean of diameter measurements in perpendicular directions., 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: mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.4], code=at0.4, itemType=ELEMENT, level=1, text=Yolk sac description, description=Narrative description about the yolk sac., 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[at0.6], code=at0.6, itemType=ELEMENT, level=1, text=Amnion description, description=Narrative description about the amnion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Number of embryos, description=Number of fetal poles or embryos observed in the gestational sac., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.16], code=at0.16, itemType=ELEMENT, level=1, text=Cardiac activity, description=Presence of cardiac activity., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0.17::Present [Cardiac activity is observed.] at0.18::Absent [No cardiac activity is observed.] at0.19::Indeterminate [It is not possible to determine if cardiac activity is present or absent.] , extendedValues=null]], description=[], protocol=[], ism_transition=[], context=[], data=[], activities=[], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000.1, 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[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= at0.1::Gestational sac , 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.v0 and specialisations or openEHR-EHR-CLUSTER.imaging_exam-lymph_node_group.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[at0.2], code=at0.2, itemType=ELEMENT, level=1, text=Mean Sac Diameter (MSD), description=Mean of diameter measurements in perpendicular directions., 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: mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.4], code=at0.4, itemType=ELEMENT, level=1, text=Yolk sac description, description=Narrative description about the yolk sac., 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[at0.6], code=at0.6, itemType=ELEMENT, level=1, text=Amnion description, description=Narrative description about the amnion., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.15], code=at0.15, itemType=ELEMENT, level=1, text=Number of embryos, description=Number of fetal poles or embryos observed in the gestational sac., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0.16], code=at0.16, itemType=ELEMENT, level=1, text=Cardiac activity, description=Presence of cardiac activity., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values= at0.17::Present [Cardiac activity is observed.] at0.18::Absent [No cardiac activity is observed.] at0.19::Indeterminate [It is not possible to determine if cardiac activity is present or absent.] , extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]