| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-uterine_cervix.v1 |
|---|---|
| Concept | Examination of the cervix |
| Description | Examination findings on physical examination of the uterine cervix. |
| Purpose | A cluster for recording findings regarding the uterine cervix on physical examination. |
| References | |
| Copyright | copyright (c) 2010 openEHR Foundation |
| Authors | Author name: Heather Leslie Organisation: Ocean Informatics, Australia Email: heather.leslie@oceaninformatics.com Date originally authored: 02/ 04/2007 |
| Other Details Language | Author name: Heather Leslie Organisation: Ocean Informatics, Australia Email: heather.leslie@oceaninformatics.com Date originally authored: 02/ 04/2007 |
| Other Details (Language Independent) |
|
| Keywords | examination, physical, cervix, uterine |
| Lifecycle | AuthorDraft |
| Language used | en |
| Citeable Identifier | 1013.1.217 |
| items | |
| Normal statements | Normal statements: A group of statements about the normality of the examination. |
| Normal statement | Normal statement: A specific statement of normality. |
| Clinical description | Clinical description: Textural description of the part examined. |
| Findings | Findings: Clinical findings. |
| Position | Position: The position in relation to the normal anatomical position.
|
| Consistency | Consistency: Consistency of cervix.
|
| Detail | Detail: More focused examination findings. Include: openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or openEHR-EHR-CLUSTER.auscultation.v1 and specialisations or openEHR-EHR-CLUSTER.inspection.v1 and specialisations or openEHR-EHR-CLUSTER.palpation.v1 and specialisations or openEHR-EHR-CLUSTER.percussion.v1 and specialisations or openEHR-EHR-CLUSTER.physical_ |
| Size | Size: Details of cervical size. Include: openEHR-EHR-CLUSTER.physical_ |
| Labour-specific findings | Labour-specific findings: Findings related to labour. |
| Effacement | Effacement: The effacement of the uterine cervix in late pregnancy or labour. 0: Uneffaced [The cervix has not changed its form.] 5: Ripe [The cervix is ripe and beginning to efface.] 10: 10% effaced [The cervix is effaced to about 10%.] 20: 20% effaced [The cervix is effaced to about 20%.] 30: 30% effaced [The cervix is effaced to about 30%.] 40: 40% effaced [The cervix is effaced to about 40%.] 50: Partially (50%) effaced [The cervix is partially effaced to about 50%.] 60: 60% effaced [The cervix is effaced to about 60%.] 70: 70% effaced [The cervix is effaced to about 70%.] 80: 80% effaced [The cervix is effaced to about 80%.] 90: 90% effaced [The cervix is effaced to about 90%.] 100: Fully effaced [The cervix is fully effaced to 100%.] |
| Thickness | Thickness: Cervical thickness.
|
| Application to presenting part | Application to presenting part: Application of cervix to fetal presenting part.
|
| Cervical os | Cervical os: The outlet of the uterus. |
| Site | Site: Identify part of cervix which is being examined.
|
| Dilation | Dilation: Dilation of cervix. |
| Estimate | Estimate: The dilation of the os. Property: Length Units: 0.0..10.0 cm Limit decimal places: 1 |
| Number of finger tips admitted | Number of finger tips admitted: Number of finger tips that are able to be admitted into the internal or external os. |
| Description | Description: Findings about the cervical os. |
| Vaginal fluid | Vaginal fluid: Details of vaginal fluid. Include: openEHR-EHR-CLUSTER.bodily_ |
| Image | Image: Drawing or image of the area examined. image/gif, image/png, image/jpeg |
| Other contributors | |
| Translators |