ARCHETYPE Palpation of Cervix (openEHR-EHR-CLUSTER.palpation_of_cervix.v1)

ARCHETYPE IDopenEHR-EHR-CLUSTER.palpation_of_cervix.v1
ConceptPalpation of Cervix
DescriptionExamination of the uterine cervix by palpation.
UseUse 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.
PurposeTo record clinical examination findings on palpation of the cervix.
ReferencesopenEHR 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
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2011-04-02
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2011-04-02
OtherDetails Language Independent{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., MD5-CAM-1.0.1=6C5B2CF06603DEE912C0B9E7A5E76614}
Keywordsexamination, physical, cervix, uterine
LifecycleOrganisationDraft
Language useden
Citeable Identifier1013.1.1468
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=Examination of the uterine cervix by palpation., archetypeConceptComment=null, otherContributors=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), originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={events=[], context=[], capabilities=[], activities=[], protocol=[], identities=[], source=[], credentials=[], state=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical Description, description=Narrative description of findings on examination of the cervix., comment=May include identification of any abnormalities or presence of trauma post-partum., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, 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=Relative Position, description=Actual cervical position in relation to the expected, central anatomical position., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anterior [The cervix is located anteriorly, towards the pubis.]
  • Intermediate [The cervix is located centrally, in the typical anatomical position.]
  • Posterior [The cervix is located posteriorly, towards the sacrum.]
  • Right [The cervix is located in the right side of the pelvis.]
  • Left [The cervix is located on the left side of the pelvis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=ELEMENT, level=1, text=Consistency, description=Consistency of the cervix., comment=Values for Bishop score., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Firm [Cervix feels firm.]
  • Intermediate [Cervix feels neither firm nor soft, but in between.]
  • Soft [Cervix feels soft.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=ELEMENT, level=1, text=Surface, description=Surface of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular/smooth [Cervix feels smooth and regular.]
  • Irregular [Cervix feels irregular.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0042], code=at0042, itemType=ELEMENT, level=1, text=Mobility, description=Narrative description of the mobility of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0043], code=at0043, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description of the tenderness of the cervix, especially on movement., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0027], code=at0027, itemType=ELEMENT, level=1, text=Thickness, description=Thickness of the cervix., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thick [Cervix is thick.]
  • Thin [Cervix is thin.]
  • Paper-thin [Cervix is very thin.]
  • Oedematous [Cervix is thickened and swollen.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=ELEMENT, level=1, text=Effacement, description=Estimation of the proportion of cervical effacement, in late pregnancy or during labour., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
Numerator: 0.0..100.0
Assumed value: false
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045], code=at0045, itemType=ELEMENT, level=1, text=Cervical Length, description=Estimation of the length of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • 0.0..<10.0 cm
    Limit decimal places: 0
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Application to Presenting Part, description=Application of the cervix to the presenting part of the fetus., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Loosely applied [Cervix is not moulded to the fetal presenting part.]
  • Tightly applied [Cervis is moulded to the fetal presenting part.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0044], code=at0044, itemType=ELEMENT, level=1, text=Anterior Lip?, description=Is an anterior lip of the cervix present?, comment=True, if an anterior lip is identified as present., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035], code=at0035, itemType=CLUSTER, level=1, text=Cervical Os, description=Findings on palpation of the specified part of the cervical os., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035]/items[at0036], code=at0036, itemType=ELEMENT, level=2, text=Site, description=Identification of the part of cervix which is being palpated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • External Os [External opening of the cervix to the vagina.]
  • Internal Os [Internal opening of the cervix to the uterus.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035]/items[at0039], code=at0039, itemType=ELEMENT, level=2, text=Dilation, description=Diameter of cervical os., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • 0.0..10.0 cm
    Limit decimal places: 0
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035]/items[at0040], code=at0040, itemType=ELEMENT, level=2, text=Description, description=Narrative description of findings on palpation of cervical os., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], contacts=[], target=[], relationships=[], description=[], ism_transition=[], content=[], details=[], other_participations=[], data=[], provider=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000, itemType=CLUSTER, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=items, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Clinical Description, description=Narrative description of findings on examination of the cervix., comment=May include identification of any abnormalities or presence of trauma post-partum., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, 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=Relative Position, description=Actual cervical position in relation to the expected, central anatomical position., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Anterior [The cervix is located anteriorly, towards the pubis.]
  • Intermediate [The cervix is located centrally, in the typical anatomical position.]
  • Posterior [The cervix is located posteriorly, towards the sacrum.]
  • Right [The cervix is located in the right side of the pelvis.]
  • Left [The cervix is located on the left side of the pelvis.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=ELEMENT, level=1, text=Consistency, description=Consistency of the cervix., comment=Values for Bishop score., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Firm [Cervix feels firm.]
  • Intermediate [Cervix feels neither firm nor soft, but in between.]
  • Soft [Cervix feels soft.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0011], code=at0011, itemType=ELEMENT, level=1, text=Surface, description=Surface of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Regular/smooth [Cervix feels smooth and regular.]
  • Irregular [Cervix feels irregular.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0042], code=at0042, itemType=ELEMENT, level=1, text=Mobility, description=Narrative description of the mobility of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0043], code=at0043, itemType=ELEMENT, level=1, text=Tenderness, description=Narrative description of the tenderness of the cervix, especially on movement., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0027], code=at0027, itemType=ELEMENT, level=1, text=Thickness, description=Thickness of the cervix., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Thick [Cervix is thick.]
  • Thin [Cervix is thin.]
  • Paper-thin [Cervix is very thin.]
  • Oedematous [Cervix is thickened and swollen.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0014], code=at0014, itemType=ELEMENT, level=1, text=Effacement, description=Estimation of the proportion of cervical effacement, in late pregnancy or during labour., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_PROPORTION, bindings=null, values=
  • Percent
Numerator: 0.0..100.0
Assumed value: false
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0045], code=at0045, itemType=ELEMENT, level=1, text=Cervical Length, description=Estimation of the length of the cervix., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • 0.0..<10.0 cm
    Limit decimal places: 0
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0032], code=at0032, itemType=ELEMENT, level=1, text=Application to Presenting Part, description=Application of the cervix to the presenting part of the fetus., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Loosely applied [Cervix is not moulded to the fetal presenting part.]
  • Tightly applied [Cervis is moulded to the fetal presenting part.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0044], code=at0044, itemType=ELEMENT, level=1, text=Anterior Lip?, description=Is an anterior lip of the cervix present?, comment=True, if an anterior lip is identified as present., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035], code=at0035, itemType=CLUSTER, level=1, text=Cervical Os, description=Findings on palpation of the specified part of the cervical os., comment=Most commonly assessed in late pregnancy or during labour., uncommonOntologyItems=null, occurencesFormal=0..2, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035]/items[at0036], code=at0036, itemType=ELEMENT, level=2, text=Site, description=Identification of the part of cervix which is being palpated., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • External Os [External opening of the cervix to the vagina.]
  • Internal Os [Internal opening of the cervix to the uterus.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035]/items[at0039], code=at0039, itemType=ELEMENT, level=2, text=Dilation, description=Diameter of cervical os., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • 0.0..10.0 cm
    Limit decimal places: 0
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0035]/items[at0040], code=at0040, itemType=ELEMENT, level=2, text=Description, description=Narrative description of findings on palpation of cervical os., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]