| ARCHETYPE ID | openEHR-EHR-CLUSTER.anatomical_pathology_exam_jm.v0 |
|---|---|
| Concept | Anatomical pathology examination |
| Description | A generic framework for findings observed during the histopathological or cytopathological examination of organs, tissues, cells, or body fluids using gross, microscopic, and ancillary testing methods. |
| Use | Use to record the findings observed during the histopathological or cytopathological examination of organs, tissues, cells, or body fluids. This archetype is designed specifically to be used in the "Test result" SLOT within the OBSERVATION.laboratory_test_result archetype, but may also be used within other ENTRY class archetypes where appropriate. |
| Misuse | Not to be used for reporting other types of laboratory test results, for example biochemistry or haematology. Not to be used to record a complete autopsy report, although individual tests performed on specimens collected during an autopsy may be represented using this archetype. |
| Purpose | To record the findings observed during the histopathological or cytopathological examination of organs, tissues, cells, or body fluids. |
| References | Derived from Histopathology test, Draft Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-11-29]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.2195 |
| Copyright | © openEHR Foundation |
| Authors | Author name: Silje Ljosland Bakke Organisation: Nasjonal IKT HF Email: silje.ljosland.bakke@nasjonalikt.no Date originally authored: 2016-11-23 |
| Other Details Language | Author name: Silje Ljosland Bakke Organisation: Nasjonal IKT HF Email: silje.ljosland.bakke@nasjonalikt.no Date originally authored: 2016-11-23 |
| Other Details (Language Independent) |
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| Keywords | histopathology, cytology, pathology |
| Lifecycle | in_development |
| UID | 4ce52f85-f342-47bc-8969-14cc64e506d7 |
| Language used | en |
| Citeable Identifier | 1013.1.7951 |
| Revision Number | 0.0.1-alpha |
| items | |
| Specimen | Specimen: Details about the specimen examined. For example, the ID of the specimen or a macroscopic description of the specimen being examined. Include: openEHR-EHR-CLUSTER.specimen.v1 and specialisations |
| Microscopic description | Microscopic description: Narrative summary of findings observed under the microscope. |
| Examination findings | Examination findings: Structured details about the anatomical pathology examination findings. Include: openEHR-EHR-CLUSTER.laboratory_ openEHR-EHR-CLUSTER.lab_ openEHR-EHR-CLUSTER.lab_ openEHR-EHR-CLUSTER.lab_ openEHR-EHR-CLUSTER.lab_ openEHR-EHR-CLUSTER.lab_ openEHR-EHR-CLUSTER.lab_ |
| Multimedia representation | Multimedia representation: Digital image, video or diagram representing the anatomical pathology examination. Multiple formats are allowed but they should represent equivalent clinical content. Include: openEHR-EHR-CLUSTER.media_ |
| Clinical interpretation | Clinical interpretation: Single word, phrase or brief description that represents the clinical meaning and significance of the anatomical pathology examination for the identified specimen. For example: 'No abnormality detected' or 'Moderate inflammation present'. Coding of the 'Clinical interpretation' with a terminology is preferred, where possible. |
| Comment | Comment: Additional narrative about the anatomical pathology examination findings, not captured in other fields. |
| Examination not done | Examination not done: Details to explicitly record that this examination was not performed. Include: openEHR-EHR-CLUSTER.exclusion_ openEHR-EHR-CLUSTER.exclusion_ |
| Other contributors | Vebjørn Arntzen, Oslo universitetssykehus, Norway Silje Ljosland Bakke, Nasjonal IKT HF, Norway (Nasjonal IKT redaktør) Kristin Eik, Kreftregisteret, Norway Anca Heyd, DIPS ASA, Norway Sabine Leh, Helse-Bergen, Norway (Nasjonal IKT redaktør) Heather Leslie, Ocean Informatics, Australia (Nasjonal IKT redaktør) Jan-Arne Ludvigsen, DIPS ASA, Norway Ole Martin Sand, DIPS ASA, Norway Ian McNicoll, Ocean Informatics, United Kingdom (Nasjonal IKT redaktør) Bjørn Næss, DIPS ASA, Norway Sveinung Sørbye, UNN HF, Norway John Tore Valand, Helse Bergen HF, Norway Torleif Trydal, Fürst AS, Norway Johan Bjerner, Fürst AS, Norway Nils Petter Tveranger, Helse Vest IKT AS, Norway |
| Translators |
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