ARCHETYPE Examination of the uterus (openEHR-EHR-CLUSTER.exam-uterus.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-uterus.v0
ConceptExamination of the uterus
DescriptionFindings observed during the palpation of the uterus.
UseUse to record a narrative description and clinical interpretation of the findings observed only by palpation of the uterus, either from an abdominal or a vaginal approach. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-abdomen, CLUSTER.exam-palpation-vagina or OBSERVATION.exam archetypes, 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 the 'Examination findings' SLOT to record additional structured physical examination findings - for example, a fetus. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element.
MisuseNot to be used when multiple modes are used simultaneously to examine a body system or anatomical structure, including inspection or auscultation. Use the CLUSTER.exam family of archetypes for this purpose. Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign. Not to be used for recording the results of an imaging examination - use the CLUSTER.imaging_exam family of archetypes for this purpose.
PurposeTo record findings observed during palpation of the uterus, in both pregnant and non-pregnant individuals.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-06-23
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2015-06-23
Other Details (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
  • Current Contact: Heather Leslie, Atomica Informatics, Australia
  • Original Namespace: org.openehr
  • Original Publisher: openEHR Foundation
  • Custodian Namespace: org.openehr
  • MD5-CAM-1.0.1: D26D96AFD939C883256DC2B3089A5F89
  • Build Uid: d81c83c2-7325-4040-b515-331897801ec4
  • 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, bimanual, palpation, examination, fundal height, Anteversion, Anteflexion, fetus, foetus, baby, abdomen, vagina, pregnant, pregnancy.
Lifecyclein_development
UID1a12f3a9-2ea3-4a7b-92f6-df3624852112
Language useden
Citeable Identifier1013.1.7948
Revision Number0.0.1-alpha
items
System or structure examinedSystem or structure examined: Identification of the examined body system or anatomical structure.
Coding of the system or structure examined with a terminology is preferred, where possible.
  • Uterus
Body siteBody site: Identification of the area of the body under examination.
For example examination of a specific area of skin. If the body site has been fully identified in the 'System or structure examined' data element, this data element becomes redundant.
Structured body siteStructured body site: A structured description of the area of the body under examination.
If the body site has been fully identified in the 'System or structure examined' or the 'Body site' data element, this SLOT becomes redundant.
Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_relative.v2 and specialisations
Clinical descriptionClinical description: Narrative description of the overall findings observed during the physical examination.
LengthLength: The estimated length from the fundus to the cervix.
Measured in centimetres.
Size estimationSize estimation: Size estimation of the uterus.
An estimation of uterine size based on physical examination, documented as either a narrative description or a comparative estimate related to size of a pregnant uterus, such as '10 weeks'. These comparisons refer to the typical uterine size at specific stages of pregnancy and provide a standardised reference framework. Alternatively, locally recognised size descriptors, such as 'orange' or 'tennis ball' may be added to the DV_TEXT data type in a template to support a predefined list of terms.
Choice of:
  •  Duration
    Allowed values: weeks
    >=0 weeks
  •  Text
Fundal heightFundal height: The vertical distance from the symphysis pubis to the top of the pregnant uterine fundus.
Usually only possible in pregnancy after approximately 20 weeks of gestation. This can be recorded as the measured distance or by identifying the height of the uterine fundus relative to identifiable anatomical landmarks, such as the pubic symphysis, umbilicus, xiphoid process).
Choice of:
  •  Coded Text
    • Not palpable [Uterus is not palpable in the abdomen.]
    • At public symphsis [The uterus is just palpable at the level of the symphysis pubis.]
    • At umbilicus [The uterus is palpable at, or about, the level of the umbilicus.]
    • At xiphisternum [The uterus is palpable at, or about, the level of the xiphisternum.]
  •  Quantity
    Property: Length
    Units: cm
TendernessTenderness: The presence or absence of pain elicited during bimanual palpation of the uterus.
  • Present [Pain is elicited on bimanual palpation of the uterus.]
  • Absent [No pain is elicited on bimanual palpation of the uterus.]
Tenderness decriptionTenderness decription: Narrative description about findings of pain or tenderness of the uterus.
For e.g. Tenderness present on anterior uterine wall, elicited during bimanual palpation, described by the patient as sharp and localized.
MobilityMobility: The degree to which the uterus can be displaced during bimanual examination, reflecting its freedom of movement within the pelvis.
  • Mobile [The uterus moves freely in response to gentle pressure during bimanual palpation, without resistance or pain.]
  • LImited [The uterus can be displaced on bimanual palpation but with some resistance or reduced range of motion.]
  • Fixed [The uterus does not move or is unable to be displaced on bimanual palpation.]
ShapeShape: The overall anatomical contour of the uterus as assessed during bimanual palpation.
For eg. Normal pear-shaped uterus.
ConsistencyConsistency: Narrative description about the texture and firmness of the uterus.
VersionVersion: The orientation of the cervix relative to the vagina.
  • Anteverted [The cervix tilts forward toward the bladder.]
  • Neutral [The cervix is roughly in line with the vagina.]
  • Retroverted [The cervix tilts backward toward the rectum.]
FlexionFlexion: The orientation of the vagina relative to the cervix.
  • Anteflexed [The body of the uterus bends forward over the bladder.]
  • Midflexed [The body is aligned with the cervix.]
  • Retroflexed [The body of the uterus bends backward toward the rectum.]
Examination findingsExamination findings: Structured details about the physical examination findings.
Include:
openEHR-EHR-CLUSTER.fetus_abdominal.v0
Multimedia representationMultimedia representation: Digital image, video or diagram representing the physical examination findings.
Include:
openEHR-EHR-CLUSTER.media_file.v1 and specialisations
Clinical interpretationClinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings.
For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible.
CommentComment: Additional narrative about the physical examination findings, not captured in other fields.
Examination not doneExamination not done: Details to explicitly record that this examination was not performed.
Include:
openEHR-EHR-CLUSTER.exclusion_exam.v1 and specialisations
Other contributorsVebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
SB Bhattacharyya, Sudisa Consultancy Services, India
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Shahla Foozonkhah, Iran ministry of health and education, Iran
Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom (openEHR Editor)
Mikkel Gaup Grønmo, FSE, Helse Nord, Norway (Nasjonal IKT redaktør)
Ingrid Heitmann, Oslo universitetssykehus HF, Norway
Hilde Hollås, DIPS ASA, Norway
Evelyn Hovenga, EJSH Consulting, Australia
Lars Ivar Mehlum, Helse Bergen HF, Norway
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom
Lars Morgan Karlsen, DIPS ASA, Norway
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Vladimir Pizzo, Hospital Sírio Libanês, Brazil
Jussara Rotzsch, UNB, Brazil
Anoop Shah, University College London, United Kingdom
Line Silsand, Universitetssykehuset i Nord-Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Nyree Taylor, Ocean Informatics, Australia (openEHR Editor)
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Jon Tysdahl, Furst medlab AS, Norway
John Tore Valand, Helse Bergen, Norway (openEHR Editor)
Nicola Ewen Hall, openEHR Fellow 2025, Jamaica
Keisha Barwise, openEHR Foundation
Translators
  • German: Nina Schewe, Natalia Strauch, Darin Leonhardt, Medizinische Hochschule Hannover, PLRI für medizinische Informatik/ Medizinische Hochschule, schewe.nina@mh-hannover.de, Strauch.Natalia@mh-hannover.de, leonhardt.darin@mh-hannover.de
  • Swedish: Erik Sundvall, Region Östergötland + Linköping University, erik.sundvall@regionostergotland.se
  • Norwegian Bokmål: Silje Ljosland Bakke, Vebjørn Arntzen, Nasjonal IKT HF, Oslo University Hospital, varntzen@ous-hf.no
  • Portuguese (Brazil): Adriana Kitajima, Hospital Alemão Oswaldo Cruz - HAOC, adrianakitajima@gmail.com
  • Greek: Erasmia Partafylla, Sigmasoft, c.partafylla@sigmasoft.gr
  • Spanish (Spain): Julio de Sosa, Servei Català de la Salut, juliodesosa@catsalut.cat