| ARCHETYPE ID | openEHR-EHR-CLUSTER.palpation_of_cervix.v1 |
|---|---|
| Concept | Palpation of Cervix |
| Description | Examination of the uterine cervix by palpation. |
| Use | Use to record examination findings on palpation of the cervix, including findings during pregnancy and labour. This archetype has been designed to be nested inside the OBSERVATION.exam archetype (and its specialisations) or other relevant CLUSTER archetypes. For example, this archetype may be used as one component of a complete record of a bimanual pelvic examination - either nested within, or placed alongside, CLUSTER.palpation_of_uterus, as required by the specific clinical scenario being modelled. |
| Purpose | To record clinical examination findings on palpation of the cervix. |
| References | openEHR Clinical Knowledge Manager [Internet]. London: openEHR Foundation. [Draft CLUSTER archetype] Examination of the cervix; [authored 2007 Apr 02, cited 2011 Aug 17]. Available from: http://www.openehr.org/knowledge/OKM.html#showArchetype_1013.1.217_4. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2011-04-02 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date originally authored: 2011-04-02 |
| Other Details (Language Independent) |
|
| Keywords | examination, physical, cervix, uterine |
| Lifecycle | OrganisationDraft |
| Language used | en |
| Citeable Identifier | 1013.1.1468 |
| items | |
| Clinical Description | Clinical Description: Narrative description of findings on examination of the cervix. May include identification of any abnormalities or presence of trauma post-partum. |
| Relative Position | Relative Position: Actual cervical position in relation to the expected, central anatomical position.
|
| Consistency | Consistency: Consistency of the cervix. Values for Bishop score.
|
| Surface | Surface: Surface of the cervix.
|
| Mobility | Mobility: Narrative description of the mobility of the cervix. |
| Tenderness | Tenderness: Narrative description of the tenderness of the cervix, especially on movement. |
| Thickness | Thickness: Thickness of the cervix. Most commonly assessed in late pregnancy or during labour.
|
| Effacement | Effacement: Estimation of the proportion of cervical effacement, in late pregnancy or during labour. Most commonly assessed in late pregnancy or during labour.
Assumed value: false |
| Cervical Length | Cervical Length: Estimation of the length of the cervix. Property: Length Units: 0.0..<10.0 cm Limit decimal places: 0 |
| Application to Presenting Part | Application to Presenting Part: Application of the cervix to the presenting part of the fetus. Most commonly assessed in late pregnancy or during labour.
|
| Anterior Lip? | Anterior Lip?: Is an anterior lip of the cervix present? True, if an anterior lip is identified as present. |
| Cervical Os | Cervical Os: Findings on palpation of the specified part of the cervical os. Most commonly assessed in late pregnancy or during labour. |
| Site | Site: Identification of the part of cervix which is being palpated.
|
| Dilation | Dilation: Diameter of cervical os. Property: Length Units: 0.0..10.0 cm Limit decimal places: 0 |
| Description | Description: Narrative description of findings on palpation of cervical os. |
| Other contributors | Rita Apelt, Department of Health,NT, Australia Stephen Chu, NEHTA, Australia Tim Garden, NTG Department of Health, Australia Tanya Gardner, CAAC, Australia Sam Heard, Ocean Informatics, Australia (Editor) Heather Leslie, Ocean Informatics, Australia (Editor) Chunlan Ma, Ocean Informatics, Australia Ian McNicoll, Ocean Informatics UK, United Kingdom Jeremy Oats, NT Health, Australia Jo Wright, NT Dept of Health, Australia (Editor) |
| Translators |