ARCHETYPE Examination of the uterus (openEHR-EHR-CLUSTER.exam-uterus.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.exam-uterus.v1
ConceptExamination of the uterus
DescriptionFor recording findings of the uterus including when pregnant.
PurposeA cluster for recording findings on physical examination of the uterus.
References
Copyright© openEHR Foundation
AuthorsIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 08/04/2007
Other Details LanguageIme avtorja: Sam Heard
Organizacija: Ocean Informatics
e-Pošta: sam.heard@oceaninformatics.com
Datum izvora: 08/04/2007
OtherDetails Language Independent{references=, MD5-CAM-1.0.1=8DC03436AB8E13BDA1F013485E53C77E}
Keywordsexamination, physical, uterus, pregnancy
LifecycleAuthorDraft
Language useden
Citeable Identifier1075.67.656
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=For recording findings of the uterus including when pregnant., archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=, subjectOfData=brez omejitev, archetypeTranslationTree=null, topLevelToAshis={source=[], state=[], description=[], content=[], provider=[], ism_transition=[], events=[], details=[], identities=[], contacts=[], activities=[], relationships=[], context=[], capabilities=[], other_participations=[], data=[], credentials=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=CLUSTER, level=1, text=Normal statements, description=A group of statements about the normality of the examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Normal statement, description=A specific statement of normality., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Clinical description, description=Textural description of the part examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1], code=at0008.1, itemType=CLUSTER, level=1, text=Findings, description=Clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0009], code=at0009, itemType=SLOT, level=2, text=Detail, description=More focused examination findings, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
openEHR-EHR-CLUSTER.exam-generic.v1 in specializacije ali
openEHR-EHR-CLUSTER.palpation.v1 in specializacije, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.24], code=at0.24, itemType=ELEMENT, level=2, text=Position, description=Position of uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anteverted [Uterine fundus is tipped forward.]
  • Retroverted [Uterine fundus is tipped backward.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1], code=at0.1, itemType=CLUSTER, level=2, text=Size, description=Information about the size of the object for examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.2], code=at0.2, itemType=ELEMENT, level=3, text=Fundal height, description=The height of the uterine fundus measured from the symphysis pubis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Lastnost: Length
Enote: 0.0..100.0 cm
Omeji število decimalk: 1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.31], code=at0.31, itemType=SLOT, level=3, text=Size, description=Details of uterine size., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
openEHR-EHR-CLUSTER.physical_properties.v1 in specializacije, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.3], code=at0.3, itemType=ELEMENT, level=3, text=Weeks of gestation, description=The size in terms of weeks of pregnancy., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Dovoljene vrednosti: tedni

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.20], code=at0.20, itemType=ELEMENT, level=3, text=Relative to anatomical markers, description=Relative size of uterus related to anatomy of person., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • At symphisis pubis [*]
  • At umbilicus [*]
  • At xiphisternum [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.4], code=at0.4, itemType=ELEMENT, level=2, text=Assessment of liquor volume, description=The relative amount of liquor present in the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=-3: Markedly reduced [The amount of liquor is much less than expected.]
-2: Reduced [The amount of liquor is definitely reduced.]
-1: Slightly reduced [The amount of liquor is slightly reduced.]
0: Normal [The amount of liquor is normal for gestation.]
1: Slightly increased [The amount of liquor is slightly increased.]
2: Increased [The amount of liquor is definitely increased.]
3: Markedly increased [The amount of liquor is greatly increased compared to normal for gestation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.12], code=at0.12, itemType=ELEMENT, level=2, text=Number of fetuses, description=The number of foetuses that are in the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.18], code=at0.18, itemType=CLUSTER, level=2, text=Fetus, description=Information about one or more foetuses., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.18]/items[at0.30], code=at0.30, itemType=SLOT, level=3, text=Fetal detail, description=Detailed information about one or more foetuses., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
openEHR-EHR-CLUSTER.exam-fetus.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Image, description=Drawing or image of the area examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/gif, image/png, image/jpeg, extendedValues=null]], protocol=[], target=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000.1, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Obvezno, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=CLUSTER, level=1, text=Normal statements, description=A group of statements about the normality of the examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Normal statement, description=A specific statement of normality., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=Clinical description, description=Textural description of the part examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1], code=at0008.1, itemType=CLUSTER, level=1, text=Findings, description=Clinical findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0009], code=at0009, itemType=SLOT, level=2, text=Detail, description=More focused examination findings, comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
openEHR-EHR-CLUSTER.exam-generic.v1 in specializacije ali
openEHR-EHR-CLUSTER.palpation.v1 in specializacije, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.24], code=at0.24, itemType=ELEMENT, level=2, text=Position, description=Position of uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anteverted [Uterine fundus is tipped forward.]
  • Retroverted [Uterine fundus is tipped backward.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1], code=at0.1, itemType=CLUSTER, level=2, text=Size, description=Information about the size of the object for examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.2], code=at0.2, itemType=ELEMENT, level=3, text=Fundal height, description=The height of the uterine fundus measured from the symphysis pubis., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Lastnost: Length
Enote: 0.0..100.0 cm
Omeji število decimalk: 1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.31], code=at0.31, itemType=SLOT, level=3, text=Size, description=Details of uterine size., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
openEHR-EHR-CLUSTER.physical_properties.v1 in specializacije, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.3], code=at0.3, itemType=ELEMENT, level=3, text=Weeks of gestation, description=The size in terms of weeks of pregnancy., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Dovoljene vrednosti: tedni

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.1]/items[at0.20], code=at0.20, itemType=ELEMENT, level=3, text=Relative to anatomical markers, description=Relative size of uterus related to anatomy of person., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • At symphisis pubis [*]
  • At umbilicus [*]
  • At xiphisternum [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.4], code=at0.4, itemType=ELEMENT, level=2, text=Assessment of liquor volume, description=The relative amount of liquor present in the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=-3: Markedly reduced [The amount of liquor is much less than expected.]
-2: Reduced [The amount of liquor is definitely reduced.]
-1: Slightly reduced [The amount of liquor is slightly reduced.]
0: Normal [The amount of liquor is normal for gestation.]
1: Slightly increased [The amount of liquor is slightly increased.]
2: Increased [The amount of liquor is definitely increased.]
3: Markedly increased [The amount of liquor is greatly increased compared to normal for gestation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.12], code=at0.12, itemType=ELEMENT, level=2, text=Number of fetuses, description=The number of foetuses that are in the uterus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=0

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.18], code=at0.18, itemType=CLUSTER, level=2, text=Fetus, description=Information about one or more foetuses., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Neobvezen, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008.1]/items[at0.18]/items[at0.30], code=at0.30, itemType=SLOT, level=3, text=Fetal detail, description=Detailed information about one or more foetuses., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Vključi:
openEHR-EHR-CLUSTER.exam-fetus.v1, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Image, description=Drawing or image of the area examined., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Neobvezen, ponavljam, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/gif, image/png, image/jpeg, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]