TEMPLATE Folliculometry (Folliculometry)

TEMPLATE ID	Folliculometry
Concept	Folliculometry
Description	To represent observations recorded during pelvic ultrasound scan performed during assisted reproduction treatment, including relevant measurements of uterus, ovaries, adnexal mass, and the rectouterine pouch.
Use	Use for representing a folliculometry during assister reproduction treatment. The element 'Modality' may be linked to DICOM CID 29 Acquisition Modality value set or other appropriate value set.
Misuse	Not to be used during pelvic ultrasound scan in other clinical settings or during pregnancy. Use the 'Pelvic ultrasound, early pregnancy', the 'Pelvic ultrasound, gynecology simple' or other appropriate templates.
Purpose	To represent observations recorded during pelvic ultrasound scan performed during assisted reproduction treatment, including relevant measurements of uterus, ovaries, adnexal mass, and the rectouterine pouch.
References
Authors	date: 2022-01-31; name: Peter Fedorcsak; organisation: Oslo University Hospital; email: p.z.fedorcsak@medisin.uio.no
Other Details Language	date: 2022-01-31; name: Peter Fedorcsak; organisation: Oslo University Hospital; email: p.z.fedorcsak@medisin.uio.no
Other Details (Language Independent)	Sem Ver: 2.0.0 Original Language: ISO_639-1::en MD5-CAM-1.0.1: 6dcd05ddd2b8681da2242db4f3ec781b PARENT:MD5-CAM-1.0.1: 7F064FABE9120B9001DA67384AD02B89
Keywords	pelvic; ultrasound; follicle; ovarian; reproduction; gynecology; ART; IVF
Language used	en
Citeable Identifier	1013.26.426
Root archetype id	openEHR-EHR-OBSERVATION.imaging_exam_result.v0
Folliculometry	Folliculometry: Record the findings and interpretation of an imaging examination performed.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test 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 date	Examination 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 status	Overall 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 timestamp	Overall test status timestamp: The date and/or time that ‘Overall test status’ was assigned.
Imaging findings	Imaging findings: Narrative description of the clinical findings.
Uterus	Uterus: Findings observed in an imaging examination targeting the uterine body, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Uterine body
Imaging findings	Imaging findings: Narrative description of the imaging findings observed during this examination.
Endometrial thickness	Endometrial thickness: Maximal measured thickness of the endometrium. Also known as the endometrial stripe. >=0 mm
Endometrial texture	Endometrial texture: Description about the endometrial texture. For example: homogeneous or heterogeneous; or describing ultrasound echogenicity as hypoechoic, isoechoic, or hyperechoic.
Left ovary	Left ovary: Findings observed in an imaging examination targeting an ovary, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Left ovary
Number of antral follicles	Number of antral follicles: The number of antral follicles. >=0
Per follicle	Per follicle: Details about a single ovarian follicle.
Diameter	Diameter: A measured diameter of an ovarian follicle. This data element has 3 occurrences to allow for measurements in 3 different axes. >=0; >=0 Units: mm cm
Description	Description: Narrative description about a single follicle. For example: may be a corpus luteum.
Right ovary	Right ovary: Findings observed in an imaging examination targeting an ovary, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Right ovary
Number of antral follicles	Number of antral follicles: The number of antral follicles. >=0
Per follicle	Per follicle: Details about a single ovarian follicle.
Diameter	Diameter: A measured diameter of an ovarian follicle. This data element has 3 occurrences to allow for measurements in 3 different axes. >=0; >=0 Units: mm cm
Description	Description: Narrative description about a single follicle. For example: may be a corpus luteum.
Adnexal mass	Adnexal 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 structure	Body structure: Identification of the body structure or region examined. Morphological abnormality Adnexal mass
Anatomical location	Anatomical 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 findings	Imaging findings: Narrative description of the imaging findings observed during this examination.
Impression	Impression: 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.
Comment	Comment: Additional narrative about the imaging findings, not captured in other fields.
Label	Label: A label for the abnormality. Use to differentiate one abnormality from another when there is more than one present at the same site.
Type	Type: 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
Diameter	Diameter: 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 pouch	Rectouterine pouch: Findings observed in an imaging examination targeting the rectouterine pouch, using radiographic techniques.
Body structure	Body structure: Identification of the body structure or region examined. Rectouterine pouch
Free fluid presence	Free fluid presence: * Present Absent
Amount of free fluid	Amount of free fluid: The amount of fluid observed. Coded Text Small Medium Large Quantity>=0; >=0 Units: l ml
Diameter	Diameter: 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
Imaging quality	Imaging 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 impression	Overall 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 diagnosis	Imaging 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.
Recommendation	Recommendation: 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.
Comment	Comment: Additional narrative about the examination not captured in other fields. For example: a note that the film was given to the patient.
State
Confounding factors	Confounding factors: Narrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.
Protocol
Organisation	Organisation: 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.
Name	Name: The unstructured name or label for the organisation. For example: 'Royal Children's Hospital'; 'ABC District Nursing Service'; 'YNWA Oslo' or 'JB Smith Lawyers'.
Identifier	Identifier: Identifier associated with the organisation.
Role	Role: 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 communication	Electronic communication: Details about a specific type of electronic communication for the organisation.
Type	Type: 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
Value	Value: 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
Comment	Comment: Additional narrative about the electronic communication not captured in other fields.
Comment	Comment: Additional narrative about the organisation not captured in other fields.
Report identifier	Report identifier: The unique identifier designated by the imaging service to the report.