TEMPLATE Imaging (Imaging)

TEMPLATE IDImaging
ConceptImaging
DescriptionNot Specified
PurposeNot Specified
References
Authorsname: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2021-12-14
Other Details Languagename: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2021-12-14
OtherDetails Language Independent{PARENT:MD5-CAM-1.0.1=7F064FABE9120B9001DA67384AD02B89, original_language=ISO_639-1::en, MD5-CAM-1.0.1=1988bb5029406389f2b883ee43f21137, sem_ver=10.0.0}
Language useden
Citeable Identifier1013.26.421
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-OBSERVATION.imaging_exam_result.v0, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0], code=at0000, itemType=OBSERVATION, level=0, text=Pelvic ultrasound, early pregnancy, description=Record the findings and interpretation of an imaging examination performed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Test name, description=The name of the imaging examination or procedure performed., comment=Coding with a terminology is strongly recommended, preferably a term specifying both modality and anatomical location, where possible. Possible candidate terminologies are LOINC, SNOMED CT or RadLex., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • Pelvic ultrasound
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  •  Date/Time
  •  Interval of Date/Time
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  •  Coded Text
    • Registered 
    • Partial 
    • Preliminary 
    • Final 
    • Amended 
    • Corrected 
    • Appended 
    • Cancelled 
    • Entered in error 
    • Unknown 
  •  Text
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  • Uterine body 
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  • Gestational sac 
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  • Fetus 
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Units:
  • mm
  • cm
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text=Impression, description=Narrative concise, clinically relevant impression of all imaging findings for the identified body structure., comment=Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-fetus.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=7, text=Comment, description=Additional narrative about the imaging findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-fetus.v0]/items[at0.4], code=at0.4, itemType=ELEMENT, level=7, text=Label, description=A label for the embryo or fetus., comment=Used to differentiate findings for each embryo or fetus in a multiple pregnancy., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-fetus.v0]/items[at0.5], code=at0.5, itemType=ELEMENT, level=7, text=Cardiac activity, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-fetus.v0]/items[at0.9], code=at0.9, itemType=ELEMENT, level=7, text=Heart rate, description=The observed heart rate for the embryo or fetus., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 /min, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-fetus.v0]/items[at0.2], code=at0.2, itemType=ELEMENT, level=7, text=Estimated gestational age, description=Estimated gestational age using radiographic techniques., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=P0D..P50W
Units:
  • Week
  • Day
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-fetus.v0]/items[at0.3], code=at0.3, itemType=ELEMENT, level=7, text=Estimated weight, description=Estimated fetal weight using radiographic techniques., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • g
  • kg
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Impression, description=Narrative concise, clinically relevant impression of all imaging findings for the identified body structure., comment=Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the imaging findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[at0.2], code=at0.2, itemType=ELEMENT, level=6, text=Mean Sac Diameter (MSD), description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=Units: mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[at0.3], code=at0.3, itemType=ELEMENT, level=6, text=Yolk sac presence, description=The presence or absence of a yolk sac., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present, single 
  • Present, multiple 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[at0.4], code=at0.4, itemType=ELEMENT, level=6, text=Yolk sac description, description=Narrative description about the yolk sac., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[at0.5], code=at0.5, itemType=ELEMENT, level=6, text=Amnion presence, description=The presence or absence of an amnion., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present, single 
  • Present, multiple 
  • Absent 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0]/items[at0.6], code=at0.6, itemType=ELEMENT, level=6, text=Amnion description, description=Narrative description about the amnion., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Impression, description=Narrative concise, clinically relevant impression of all imaging findings for the identified body structure., comment=Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the imaging findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.13], code=at0.13, itemType=ELEMENT, level=5, text=Length, description=The length of the 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • mm
  • cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.14], code=at0.14, itemType=ELEMENT, level=5, 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=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • mm
  • cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.15], code=at0.15, itemType=ELEMENT, level=5, text=Depth, description=The depth or height of the uterus., comment=Usually measured in the sagittal plane, from the anterior to posterior walls, perpendicular to the length. Also known as 'antero-posterior diameter'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • mm
  • cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.16], code=at0.16, itemType=ELEMENT, level=5, text=Endometrium description, description=Narrative description about the endometrium., comment=For example: thickness, focal abnormalities, echogenicity, and the presence and characteristics of fluid or masses in the cavity. Record structured details about any morphological abnormality using CLUSTER.imaging_exam-abnormality nested within the 'Additional details' SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.17], code=at0.17, itemType=ELEMENT, level=5, text=Endometrial thickness, description=Maximal measured thickness of the endometrium., comment=Also known as the endometrial stripe., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.18], code=at0.18, itemType=ELEMENT, level=5, text=Endometrial texture, description=Description about the endometrial texture., comment=For example: homogeneous or heterogeneous; or describing ultrasound echogenicity as hypoechoic, isoechoic, or hyperechoic., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.5], code=at0.5, itemType=ELEMENT, level=5, text=Intrauterine pregnancy, description=The presence or absence of an intrauterine pregnancy., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present, viable 
  • Absent 
  • Indeterminate 
  • Present, non-viable 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.2], code=at0.2, itemType=ELEMENT, level=5, text=Number of gestations, description=Number of gestations observed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Count>=0
  •  Coded Text
    • Single 
    • Multiple 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.3], code=at0.3, itemType=ELEMENT, level=5, text=Chorionicity, description=The number of chorionic (outer) membranes or placentas observed in a multiple pregnancy., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Count>=0
  •  Coded Text
    • Monochorionic 
    • Dichorionic 
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.4], code=at0.4, itemType=ELEMENT, level=5, text=Amnionicity, description=The number of amnions (inner membranes) or yolk sacs observed in a multiple pregnancy., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Count
  •  Text
  •  Coded Text
    • Monoamnionic 
    • Diamnionic 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.19], code=at0.19, itemType=ELEMENT, level=5, 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-abnormality nested within the 'Additional details' SLOT., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.20], code=at0.20, itemType=ELEMENT, level=5, text=Myometrial walls, description=Description of the relative thickness of the endometrial walls., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Coded Text
    • Symmetrical 
    • Asymmetrical 
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  • Anteverted 
  • Axial 
  • Retroverted 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.29], code=at0.29, itemType=ELEMENT, level=5, text=Uterine flexion, description=The axis of the uterine fundus relative to the axis of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anteflexed 
  • Retroflexed 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0]/items[at0.32], code=at0.32, itemType=ELEMENT, level=5, text=IUD presence, description=The presence or absence of an intrauterine contraceptive device., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
  • Indeterminate 
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  • Rectouterine pouch 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=5, text=Imaging findings, description=Narrative description of the imaging findings observed during this examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0], code=at0000.1.1, itemType=CLUSTER, level=5, text=Imaging examination of an adnexal mass, description=Findings of a morphological abnormality observed in an imaging examination targeting a mass near the uterus, including the ovaries, fallopian tubes, and connecting tissues, using radiographic techniques., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0001.1.1], code=at0001.1.1, itemType=ELEMENT, level=6, text=Body structure, description=Identification of the body structure or region examined., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Morphological abnormality 
  • Adnexal mass 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=6, text=Anatomical location, description=Simple body site for the identified structure., comment=If the anatomical location of the identified body structure is known, this data element is redundant., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Imaging findings, description=Narrative description of the imaging findings observed during this examination., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Impression, description=Narrative concise, clinically relevant impression of all imaging findings for the identified body structure., comment=Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the imaging findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.2], code=at0.2, itemType=ELEMENT, level=6, text=Label, description=A label for the abnormality., comment=Use to differentiate one abnormality from another when there is more than one present at the same site., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.3.1], code=at0.3.1, itemType=ELEMENT, level=6, text=Type, description=The type of abnormality., comment=Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Unilocular cyst 
  • Unilocular-solid cyst 
  • Multilocular cyst 
  • Multilocular-solid cyst 
  • Solid tumour 
  • Indeterminate 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.4], code=at0.4, itemType=ELEMENT, level=6, text=Diameter, description=A measured diameter of the abnormality., comment=This data element has 3 occurrences to allow for 3 measurements in different axes., uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • mm
  • cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.9], code=at0.9, itemType=ELEMENT, level=6, text=Shape, description=The shape of the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.10], code=at0.10, itemType=ELEMENT, level=6, text=Texture, description=The texture of the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.11], code=at0.11, itemType=ELEMENT, level=6, text=Definition, description=The definition of the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Coded Text
    • Well-defined 
    • Poorly-defined 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.14], code=at0.14, itemType=ELEMENT, level=6, text=Contour, description=The contour of the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.15], code=at0.15, itemType=ELEMENT, level=6, text=Margin, description=The margin of the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.16], code=at0.16, itemType=ELEMENT, level=6, text=Calcification, description=Presence of calcification in the abnormality., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.19], code=at0.19, itemType=ELEMENT, level=6, text=Effect, description=Narrative description about the effect of the abnormality on surrounding structures., comment=For example: 'pressing on blood vessel'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.20], code=at0.20, itemType=ELEMENT, level=6, text=Vascularisation, description=Assessment of the blood flow to the abnormality., comment=Often determined by colour doppler or similar., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Coded Text
    • None 
    • Mild 
    • Moderate 
    • Marked 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.0.15], code=at0.0.15, itemType=ELEMENT, level=6, text=Solid diameter, description=A measured diameter of the largest solid tissue component., comment=This data element has 3 occurrences to allow for 3 measurements in different axes., uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • mm
  • cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.0.8], code=at0.0.8, itemType=ELEMENT, level=6, text=Number of cyst locules, description=The number of cyst locules in the adnexal mass., comment=null, uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.0.13], code=at0.0.13, itemType=ELEMENT, level=6, text=Number of papillary projections, description=The number of papillary projections in the adnexal mass., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=>=0, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0]/items[at0.0.14], code=at0.0.14, itemType=ELEMENT, level=6, text=Maximal septum width, description=The measured width of the thickest septum., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0 mm, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[at0006], code=at0006, itemType=ELEMENT, level=5, text=Impression, description=Narrative concise, clinically relevant impression of all imaging findings for the identified body structure., comment=Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=5, text=Comment, description=Additional narrative about the imaging findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[at0.2], code=at0.2, itemType=ELEMENT, level=5, text=Free fluid presence, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Present 
  • Absent 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[at0.5], code=at0.5, itemType=ELEMENT, level=5, text=Amount of free fluid, description=The amount of fluid observed., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Coded Text
    • Small 
    • Medium 
    • Large 
  •  Quantity>=0; >=0
    Units:
    • l
    • ml
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v0]/items[at0.9], code=at0.9, itemType=ELEMENT, level=5, text=Diameter, description=A measured diameter of the recto-uterine pouch., comment=This data element has 3 occurrences to allow for measurements in 3 different axes., uncommonOntologyItems=null, occurencesFormal=0..3, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_QUANTITY, bindings=null, values=>=0; >=0
Units:
  • mm
  • cm
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0056], code=at0056, itemType=ELEMENT, level=4, text=Comparison, description=Narrative description about the comparison of this examination, with previous similar studies., comment=Also use this data element to indicate if no comparison images and/or reports are available., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Imaging quality, description=Assessment about the quality of the examination., comment=Coding of the imaging quality with a value set is recommended. For example: 'excellent, good, fair, poor, and non-diagnostic'; or 'adequate, suboptimal and inadequate'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0057], code=at0057, itemType=ELEMENT, level=4, text=Imaging quality description, description=Narrative description about the quality of the examination., comment=For example: the nature of any limitations and their impact on interpretation; recommendation that the examination should be repeated; or whether an alternative method of assessment might be more appropriate., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Overall impression, description=Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate., comment=Also referred to as 'Opinion' or 'Conclusion'. Usually equivalent to the FHIR DiagnosticReport.conclusion., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0058], code=at0058, itemType=ELEMENT, level=4, text=Imaging differential diagnosis, description=Single word, phrase or brief description representing a possible condition or diagnosis., comment=This data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0020], code=at0020, itemType=ELEMENT, level=4, text=Imaging diagnosis, description=Single word, phrase or brief description representing the likely condition or diagnosis., comment=This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0059], code=at0059, itemType=ELEMENT, level=4, text=Recommendation, description=Suggestion for further imaging, investigations and/or referral, and associated rationale., comment=This data element has 0..* occurrences to allow for more than one recommendation. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/data[at0003]/items[at0023], code=at0023, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the examination not captured in other fields., comment=For example: a note that the film was given to the patient., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/state[at0047], code=at0047, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=3, text=State, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/data[at0001]/events[at0002]/state[at0047]/items[at0048], code=at0048, itemType=ELEMENT, level=4, text=Confounding factors, description=Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025], code=at0025, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0033], code=at0033, itemType=ELEMENT, level=2, text=Report identifier, description=The unique identifier designated by the imaging service to the report., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027], code=at0027, itemType=CLUSTER, level=2, text=Examination request details, description=Details concerning a single examination requested., comment=Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0031], code=at0031, itemType=ELEMENT, level=3, text=Receiver order identifier, description=The local identifier assigned to the imaging examination order by the order filler, usually by the Radiology Information System (RIS)., comment=Assigning an identifier to a request by the Radiology lnformation System (RIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  Coded Text Value set: external
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0028], code=at0028, itemType=ELEMENT, level=3, text=Requester order identifier, description=The local identifier assigned to the order by the order requester., comment=Equivalent to the HL7 Placer Order Identifier., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0027]/items[at0029], code=at0029, itemType=ELEMENT, level=3, text=Examination requested name, description=Identification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed., comment=null, 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0087], code=at0087, itemType=ELEMENT, level=2, text=Technique, description=Name of the technique or technical procedure used to capture the image/s., comment=Coding of the 'Technique' with a terminology is pemitted. Multiple occurrences allow for identification of one or more techniques. If the technique needs to be recorded at study level, use the 'Technique' data element within the CLUSTER.imaging_study_detail archetype., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0049], code=at0049, itemType=ELEMENT, level=2, text=Technique description, description=Narrative description about the technique or technical procedure used to capture the image/s., comment=Use this data element to provide an outline of technique, including technical limitations or deviation from the normal technique. For example: '5 mm axial images from the lung bases through the pubic symphysis were acquired following the administration of intravenous and oral contrast. Coronal and Sagittal reformatted images were constructed from the source data., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0088], code=at0088, itemType=ELEMENT, level=2, text=Procedure, description=Identification of the clinical procedure or management used as part of capturing the image/s., comment=In implementations, RM links can be created from this data element to relevant ACTION.medication, ACTION.procedure or similar archetypes stored within the health record that document the actual clinical procedures and related activities carried out. If the procedure needs to be recorded at study level, use the 'Procedure' data element within the CLUSTER.imaging_study_details archetype instead., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[at0062], code=at0062, itemType=ELEMENT, level=2, text=Procedure description, description=Narrative description about the clinical procedure or other clinical considerations used to capture the image/s., comment=Use this data element to describe a summary of the clinical procedure, patient positioning, interventions such as Valsalva manoeuvre, and administration of contrast agent, radiopharmaceuticals and/or treatments as part of the imaging study. For example: '80 ml of Isovue-370 was administered intravenously using a bolus-tracking technique centered on the main pulmonary artery'. It can also be used to record an overview of any issues, complications or adverse reactions encountered., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0], code=at0000, itemType=CLUSTER, level=2, text=Imaging study details, description=Details about specific images, including DICOM studies, series or instances., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Study identifier, description=Unique identifier for the imaging study assigned by the radiology service., comment=Also known in FHIR as ImagingStudy.identifier., uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0002], code=at0002, itemType=ELEMENT, level=3, text=Study status, description=The current state of the Study., comment=Also known in FHIR as ImagingStudy.status., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Registered 
  • Available 
  • Cancelled 
  • Unknown 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0014], code=at0014, itemType=ELEMENT, level=3, text=Study description, description=Institution-generated description or classification of the study (component) performed., comment=Also known in FHIR as ImagingStudy.description and DICOM as 'Study description'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0007], code=at0007, itemType=ELEMENT, level=3, text=Modality, description=The type of diagnostic equipment, or function or technique of that equipment, that originally acquired, the data used to create the image study., comment=Coding of the 'Modality' with a value set is recommended. For example, the DICOM CID 29 Acquisition Modality value set. This data element has multiple occurrences to allow specification of submodalities such as 'Doppler' as a form of 'Ultrasound'. Also known in FHIR as ImagingStudy.modality., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0008], code=at0008, itemType=ELEMENT, level=3, text=Study date, description=Date and time the study started., comment=Also known in FHIR as ImagingStudy.started., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0009], code=at0009, itemType=ELEMENT, level=3, text=Study end point, description=Location of where to query for imaging content and metadata (QIDO-RS, WADO-RS, or WADO-URI)., comment=The network service providing access (e.g., query, view, or retrieval) for the study. Also known in FHIR as ImagingStudy.endpoint., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  URI
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0012], code=at0012, itemType=ELEMENT, level=3, text=Procedure reason, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0015], code=at0015, itemType=CLUSTER, level=3, text=Imaging series details, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0015]/items[at0016], code=at0016, itemType=ELEMENT, level=4, text=Series identifier, description=Unique identifier for the imaging study assigned by the radiology service., comment=Also known in FHIR as ImagingStudy.identifier., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0015]/items[at0017], code=at0017, itemType=ELEMENT, level=4, text=Series number, description=The numeric identifier of this series in the study., comment=Also known in FHIR as ImagingStudy.series.number., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0015]/items[at0018], code=at0018, itemType=ELEMENT, level=4, text=Modality, description=The type of diagnostic equipment, or function or technique of that equipment, that originally acquired, the data used to create the image series., comment=Coding of the 'Modality' with a value set is recommended. For example, the DICOM CID 29 Acquisition Modality value set. This data element has multiple occurrences to allow specification of submodalities such as 'Doppler' as a form of 'Ultrasound'. Also known in FHIR as ImagingStudy.series.modality., 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=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0015]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Number of instances, description=The number of instances contained in the series., comment=Also known in FHIR as ImagingStudy.series.numberOfInstances., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0015]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=Series end point, description=Location of where to query for imaging content and metadata (QIDO-RS, WADO-RS, or WADO-URI)., comment=The network service providing access (e.g., query, view, or retrieval) for the series. Also known in FHIR as ImagingStudy.series.endpoint., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  URI
  •  Text
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0013], code=at0013, itemType=ELEMENT, level=3, text=Technique, description=*, comment=Coding of the 'Technique' with a terminology is recommended. Multiple occurrences allow for identification of one or more techniques. If the technique needs to be recorded at the whole of result level, use the 'Technique' data element within the OBSERVATION.imaging_exam_result archetype instead., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-OBSERVATION.imaging_exam_result.v0]/protocol[at0025]/items[openEHR-EHR-CLUSTER.imaging_study_details.v0]/items[at0011], code=at0011, itemType=ELEMENT, level=3, text=Procedure, description=Identification of the clinical procedure or management used as part of capturing the study., comment=Coding of the 'Procedure ' with a terminology is recommended. In implementations, RM links can be created from this data element to relevant ACTION.medication, ACTION.procedure or similar archetypes stored within the health record that document the actual clinical procedures and related activities carried out. Multiple occurrences allow for identification of one or more techniques. If the procedure needs to be recorded at the whole of result level, use the 'Procedure' data element within the OBSERVATION.imaging_exam_result archetype instead., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], templateType=normal]