TEMPLATE Pelvic ultrasound simple (Pelvic ultrasound simple)

TEMPLATE IDPelvic ultrasound simple
ConceptPelvic ultrasound simple
DescriptionTo represent data points recorded during a simple pelvic ultrasound scan, including description and simple measures of uterus, ovaries, adnexal mass and the rectouterine pouch.
UseUse for representing a simple pelvic ultrasound scan in non-pregnant individuals. The element 'Modality' may be linked to DICOM CID 29 Acquisition Modality value set or other appropriate value set.
MisuseNot to be used during pelvic ultrasound scan in pregnancy. Use the 'Pelvic ultrasound, early pregnancy' or other appropriate template.
PurposeTo represent data points recorded during a simple pelvic ultrasound scan, including description and simple measures of uterus, ovaries, adnexal mass and the rectouterine pouch.
References
Authorsdate: 2022-01-26; name: Peter Fedorcsak; organisation: Oslo University Hospital; email: peterfe@mail.uio.no
Other Details Languagedate: 2022-01-26; name: Peter Fedorcsak; organisation: Oslo University Hospital; email: peterfe@mail.uio.no
Other Details (Language Independent)
  • Sem Ver: 5.2.0
  • MD5-CAM-1.0.1: 3fe4c49e5c9db9ffd407386254725419
  • PARENT:MD5-CAM-1.0.1: 7F064FABE9120B9001DA67384AD02B89
  • Original Language: ISO_639-1::en
Keywordspelvic; ultrasound; reproduction; gynecology; ART; IVF
Language useden
Citeable Identifier1013.26.424
Root archetype idopenEHR-EHR-OBSERVATION.imaging_exam_result.v0
Pelvic ultrasound, gynecology simplePelvic ultrasound, gynecology simple: Record the findings and interpretation of an imaging examination performed.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test nameTest name: The name of the imaging examination or procedure performed.
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.
  • Pelvic ultrasound
Examination dateExamination date: The date and time or interval of data and time when the imaging examination was carried out.
  •  Date/Time
  •  Interval of Date/Time
Overall test statusOverall test status: The status of the imaging examination result as a whole.
The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.
  •  Coded Text
    • Registered 
    • Partial 
    • Preliminary 
    • Final 
    • Amended 
    • Corrected 
    • Appended 
    • Cancelled 
    • Entered in error 
    • Unknown 
  •  Text
Overall test status timestampOverall test status timestamp: The date and/or time that ‘Overall test status’ was assigned.
Imaging findingsImaging findings: Narrative description of the clinical findings.
Uterine bodyUterine body: Findings observed in an imaging examination targeting the uterine body, using radiographic techniques.
Body structureBody structure: Identification of the body structure or region examined.
  • Uterine body 
Imaging findingsImaging findings: Narrative description of the imaging findings observed during this examination.
ImpressionImpression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure.
Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
DepthDepth: The depth or height of the uterus.
Usually measured in the sagittal plane, from the anterior to posterior walls, perpendicular to the length. Also known as 'antero-posterior diameter'.
>=0; >=0
Units:
  • mm
  • cm
Endometrium descriptionEndometrium description: Narrative description about the endometrium.
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.
Endometrial thicknessEndometrial thickness: Maximal measured thickness of the endometrium.
Also known as the endometrial stripe.
>=0 mm
Uterine axisUterine axis: The axis of the cervix relative to the vagina.
Also known as 'position'.
  • Anteverted 
  • Axial 
  • Retroverted 
Uterine flexionUterine flexion: The axis of the uterine fundus relative to the axis of the cervix.
  • Anteflexed 
  • Retroflexed 
Left ovaryLeft ovary: Findings observed in an imaging examination targeting an ovary, using radiographic techniques.
Body structureBody structure: Identification of the body structure or region examined.
  • Left ovary 
Imaging findingsImaging findings: Narrative description of the imaging findings observed during this examination.
ImpressionImpression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure.
Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
DiameterDiameter: A measured diameter of the ovary.
This data element has 3 occurrences to allow for measurements in 3 different axes.
>=0; >=0
Units:
  • mm
  • cm
Largest follicle diameterLargest follicle diameter: A measured diameter of the largest ovarian follicle.
This data element has 3 occurrences to allow for measurements in 3 different axes.
>=0; >=0
Units:
  • mm
  • cm
Number of antral folliclesNumber of antral follicles: The number of antral follicles.
>=0
Right ovaryRight ovary: Findings observed in an imaging examination targeting an ovary, using radiographic techniques.
Body structureBody structure: Identification of the body structure or region examined.
  • Right ovary 
Imaging findingsImaging findings: Narrative description of the imaging findings observed during this examination.
ImpressionImpression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure.
Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
DiameterDiameter: A measured diameter of the ovary.
This data element has 3 occurrences to allow for measurements in 3 different axes.
>=0; >=0
Units:
  • mm
  • cm
Largest follicle diameterLargest follicle diameter: A measured diameter of the largest ovarian follicle.
This data element has 3 occurrences to allow for measurements in 3 different axes.
>=0; >=0
Units:
  • mm
  • cm
Number of antral folliclesNumber of antral follicles: The number of antral follicles.
>=0
Adnexal massAdnexal mass: 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.
Body structureBody structure: Identification of the body structure or region examined.
  • Adnexal mass 
Anatomical locationAnatomical location: Simple body site for the identified structure.
If the anatomical location of the identified body structure is known, this data element is redundant.
Imaging findingsImaging findings: Narrative description of the imaging findings observed during this examination.
ImpressionImpression: Narrative concise, clinically relevant impression of all imaging findings for the identified body structure.
Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
LabelLabel: A label for the abnormality.
Use to differentiate one abnormality from another when there is more than one present at the same site.
TypeType: The type of abnormality.
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.
  • Unilocular cyst 
  • Unilocular-solid cyst 
  • Multilocular cyst 
  • Multilocular-solid cyst 
  • Solid tumour 
  • Indeterminate 
DiameterDiameter: A measured diameter of the abnormality.
This data element has 3 occurrences to allow for 3 measurements in different axes.
>=0; >=0
Units:
  • mm
  • cm
Rectouterine pouchRectouterine pouch: Findings observed in an imaging examination targeting the rectouterine pouch, using radiographic techniques.
Body structureBody structure: Identification of the body structure or region examined.
  • Rectouterine pouch 
Imaging findingsImaging findings: Narrative description of the imaging findings observed during this examination.
Free fluid presenceFree fluid presence: *
  • Present 
  • Absent 
Amount of free fluidAmount of free fluid: The amount of fluid observed.
  •  Coded Text
    • Small 
    • Medium 
    • Large 
  •  Quantity>=0; >=0
    Units:
    • l
    • ml
DiameterDiameter: A measured diameter of the recto-uterine pouch.
This data element has 3 occurrences to allow for measurements in 3 different axes.
>=0; >=0
Units:
  • mm
  • cm
ComparisonComparison: Narrative description about the comparison of this examination, with previous similar studies.
Also use this data element to indicate if no comparison images and/or reports are available.
Imaging qualityImaging quality: Assessment about the quality of the examination.
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'.
Overall impressionOverall impression: Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate.
Also referred to as 'Opinion' or 'Conclusion'. Usually equivalent to the FHIR DiagnosticReport.conclusion.
Imaging differential diagnosisImaging differential diagnosis: Single word, phrase or brief description representing a possible condition or diagnosis.
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.
Imaging diagnosisImaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis.
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.
RecommendationRecommendation: Suggestion for further imaging, investigations and/or referral, and associated rationale.
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.
CommentComment: Additional narrative about the examination not captured in other fields.
For example: a note that the film was given to the patient.
State
Confounding factorsConfounding factors: Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.
Protocol
OrganisationOrganisation: An identified formal entity or informal grouping of people.
For example: a company, institution, corporation, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who will act as carers or support.
NameName: The unstructured name or label for the organisation.
For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
IdentifierIdentifier: Identifier associated with the organisation.
RoleRole: The relationship or role of the organisation to the individual or subject of care.
For example: Lawyer, insurance company, school, health clinic, hospital, or informal support network.
Electronic communicationElectronic communication: Details about a specific type of electronic communication for the organisation.
TypeType: The type or medium for electronic communication.
The range of electronic communication mediums includes, but is not limited to use of: telephone, cellular phone, email, pager, fax, conferencing tool or social media.
  •  Coded Text
    • Mobile (cellular) telephone 
    • Telephone (excluding mobile telephone) 
    • Email 
    • Pager 
    • Fax 
  •  Text
ValueValue: The unique combination of alphanumeric characters, meaningful for the identified type or medium of electronic communication.
For example: area code + landline phone/pager number; country code + mobile phone number; email address; or skype contact name.
  •  Text
  •  URI
CommentComment: Additional narrative about the electronic communication not captured in other fields.
CommentComment: Additional narrative about the organisation not captured in other fields.
Report identifierReport identifier: The unique identifier designated by the imaging service to the report.