ARCHETYPE Imaging examination of the uterine body (openEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0)

ARCHETYPE IDopenEHR-EHR-CLUSTER.imaging_exam-uterine_body.v0
ConceptImaging examination of the uterine body
DescriptionFindings observed in an imaging examination targeting the uterine body, using radiographic techniques.
UseUse to record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting the uterine body. The scope of this archetype does not include detailed information about the uterine cervix, however CLUSTER.imaging_exam-cervix may be nested within the 'Additional details' SLOT in this archetype as necessary. This archetype has been designed to be used in the 'Structured imaging findings' SLOT within the OBSERVATION.imaging_exam_result archetype, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Additional details' SLOT within this archetype to record additional nested levels of structured imaging findings for related body substructures, pregnancy findings, details about structural abnormalities such as a bicornuate uterus, morphological abnormalities such as a myometrial mass or intracavity lesion, or an adnexal mass.
MisuseNot to be used to record findings outside the specified body structure or region. Use other archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record findings of the uterine cervix. Use CLUSTER.imaging_exam-cervix for this purpose. Not to be used to record details related to the overall findings, context or technical details related to a complete imaging examination test result. Use the OBERSERVATION.imaging_exam_result for this purpose. For example, comments on the study quality, differential diagnoses, and overall impression.
PurposeTo record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting the uterine body.
ReferencesDerived from: <Add reference to original resource here>

Abuhamad A, Chaoui R, Jeanty P, Paladini D, Walsh E. Ultrasound in Obstetrics and Gynecology: A Practical Approach [Internet]. The Global Library of Women’s Medicine; 2014 [cited 2021 Dec 21]. 322 p. Available from: https://www.glowm.com/pdf/Ultrasound_in_obstetrics_and_gynecology-chapter11.pdf.

AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Female Pelvis. J Ultrasound Med. 2020 May;39(5):E17-E23. doi: 10.1002/jum.15205. Epub 2020 Mar 9. PMID: 32150295. Available from: https://www.aium.org/resources/guidelines/femalePelvis.pdf.

American Institute of Ultrasound in Medicine; Society for Reproductive Endocrinology and Infertility; American Society of Reproductive Medicine. AIUM practice guideline for ultrasonography in reproductive medicine. J Ultrasound Med. 2009 Jan;28(1):128-37. PMID: 19106372. Available from: https://www.aium.org/resources/guidelines/reproductiveMed.pdf.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2021-11-24
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2021-11-24
Other Details (Language Independent)
  • Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
  • Custodian Organisation: Ocean Informatics
  • References: Derived from: Abuhamad A, Chaoui R, Jeanty P, Paladini D, Walsh E. Ultrasound in Obstetrics and Gynecology: A Practical Approach [Internet]. The Global Library of Women’s Medicine; 2014 [cited 2021 Dec 21]. 322 p. Available from: https://www.glowm.com/pdf/Ultrasound_in_obstetrics_and_gynecology-chapter11.pdf. AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Female Pelvis. J Ultrasound Med. 2020 May;39(5):E17-E23. doi: 10.1002/jum.15205. Epub 2020 Mar 9. PMID: 32150295. Available from: https://www.aium.org/resources/guidelines/femalePelvis.pdf. American Institute of Ultrasound in Medicine; Society for Reproductive Endocrinology and Infertility; American Society of Reproductive Medicine. AIUM practice guideline for ultrasonography in reproductive medicine. J Ultrasound Med. 2009 Jan;28(1):128-37. PMID: 19106372. Available from: https://www.aium.org/resources/guidelines/reproductiveMed.pdf.
  • Original Namespace: com.oceaninformatics
  • Original Publisher: Ocean Informatics
  • Custodian Namespace: com.oceaninformatics
  • MD5-CAM-1.0.1: 280BA5392341DA3A440DCABAB81B52FA
  • Build Uid: ce8f62df-d67f-421b-9099-8e0deb21ef36
  • Ip Acknowledgements: This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.
  • Revision: 0.0.1-alpha
Keywords
Lifecyclein_development
UID5151ba8a-07a5-4b19-a0fb-4d6c74972a2b
Language useden
Citeable Identifier1013.1.2185
Revision Number0.0.1-alpha
items
Body structureBody structure: Identification of the body structure or region examined.
Body siteBody site: Identification of the area of the body under examination.
For example: a lymph node group (body structure) which found in the 'Right axilla'. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable. If the body site has been fully identified in the 'Body structure' data element, this data element becomes redundant.
Structured body siteStructured body site: Structured details about the area of the body under examination.
For example: details about a relative anatomical location, such as '2cm distal to the appendix'. If the body site has been fully identified in the 'Body structure' or 'Body site' data elements, then this SLOT becomes redundant.
Include:
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_relative.v2 and specialisations or
openEHR-EHR-CLUSTER.anatomical_location_circle.v1 and specialisations
Imaging findingsImaging findings: Narrative description of the imaging findings observed during this examination.
Additional detailsAdditional details: Additional structured details about imaging findings for the identified body structure or region, or findings of related structures.
Include:
openEHR-EHR-CLUSTER.imaging_exam-cervix.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-gestational_sac.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-fetus.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-lymph_node_group.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0 and specialisations or
openEHR-EHR-CLUSTER.imaging_exam-abnormality.v0 and specialisations
ImpressionImpression: Single word, phrase or brief description that represents the clinical meaning and significance of all imaging findings for the identified body structure.
Also referred to as 'Interpretation' or 'Opinion'. For example: 'No abnormality detected' or 'Free fluid present'. Coding of the 'Impression' with a terminology is permitted, if useful. Multiple occurrences allow for more than one coded impression. A narrative description may include a comparison with previous studies of the identified body structure, if appropriate.
CommentComment: Additional narrative about the imaging findings of the body structure, not captured in other fields.
LengthLength: The length of the uterus.
Usually measured in the midsagittal plane, from the outer serosal surface of the fundus to the external os of the cervix.
Property: Length
Units:
  • >=0.0 mm
    Limit decimal places: 0
  • >=0.0 cm
    Limit decimal places: 1
WidthWidth: The width of the uterus.
Usually measured at the widest dimension in the transverse or coronal plane, perpendicular to the length.
Property: Length
Units:
  • >=0.0 mm
    Limit decimal places: 0
  • >=0.0 cm
    Limit decimal places: 1
DepthDepth: The depth or height of the uterus.
Usually measured in the sagittal plane, from the anterior to posterior walls, perpendicular to the length. Also known as 'antero-posterior diameter'.
Property: Length
Units:
  • >=0.0 mm
    Limit decimal places: 0
  • >=0.0 cm
    Limit decimal places: 1
Endometrium descriptionEndometrium description: Narrative description about the endometrium.
For example: thickness, focal abnormalities, echogenicity, and the presence and characteristics of fluid or masses in the cavity. Record structured details about any morphological abnormality using CLUSTER.imaging_exam-abnormality nested within the 'Additional details' SLOT.
Endometrial thicknessEndometrial thickness: Maximal measured thickness of the endometrium.
Also known as the endometrial stripe.
Property: Length
Units: >=0.0 mm
Limit decimal places: 0
Endometrial textureEndometrial texture: Description about the endometrial texture.
For example: homogeneous or heterogeneous; or describing ultrasound echogenicity as hypoechoic, isoechoic, or hyperechoic.
Intrauterine pregnancyIntrauterine pregnancy: The presence or absence of an intrauterine pregnancy.
  • Present, viable [Intrauterine pregnancy is observed, with associated cardiac activity.]
  • Absent [No intrauterine pregnancy is observed.]
  • Indeterminate [It is not possible to determine if an intrauterine pregnancy is present of absent.]
  • Present, non-viable [Intrauterine pregnancy is observed, with no associated cardiac activity.]
Number of gestationsNumber of gestations: Number of gestations observed.
Choice of:
  •  Count
    min: >=0

  •  Coded Text
    • Single [A single gestation is observed.]
    • Multiple [More than one gestation is observed.]
ChorionicityChorionicity: The number of chorionic (outer) membranes or placentas observed in a multiple pregnancy.
Choice of:
  •  Count
    min: >=0

  •  Coded Text
    • Monochorionic [One chorion or placenta is observed.]
    • Dichorionic [Two chorions or placentae are observed.]
  •  Text
AmnionicityAmnionicity: The number of amnionic sacks (inner membranes) observed in a multiple pregnancy.
Choice of:
  •  Count
  •  Text
  •  Coded Text
    • Monoamnionic [One amniotic sac is observed.]
    • Diamnionic [Two amniotic sacs are observed.]
Myometrium descriptionMyometrium description: Narrative description about the myometrium.
For example: contour changes, texture, masses, and cysts as well as symmetry between the anterior and posterior segments of the myometrium. Record structured details about any morphological abnormality using CLUSTER.imaging_exam-abnormality nested within the 'Additional details' SLOT.
Myometrial wallsMyometrial walls: Description of the relative thickness of the endometrial walls.
Choice of:
  •  Text
  •  Coded Text
    • Symmetrical [The thickness of the myometrial walls are symmetrical.]
    • Asymmetrical [The thickness of the myometrial walls are not symmetrical.]
Myometrial textureMyometrial texture: Description about the myometrial texture.
For example: homogeneous or heterogeneous.
Junctional zoneJunctional zone: Description about the junctional zone of the myometrium.
For example: regular, interrupted, or not visible.
Junctional zone thicknessJunctional zone thickness: Measured thickness of the junctional zone.
Property: Length
Units: >=0.0 mm
Limit decimal places: 0
Uterine axisUterine axis: The axis of the cervix relative to the vagina.
Also known as 'position'.
  • Anteverted [The vagina-cervix angle faces anteriorly.]
  • Axial [The cervix is in the same axis as the vagina.]
  • Retroverted [The vagina-cervix angle faces posteriorly.]
Uterine flexionUterine flexion: The axis of the uterine fundus relative to the axis of the cervix.
  • Anteflexed [The cervix-body angle faces anteriorly.]
  • Retroflexed [The cervix-body angle faces posteriorly.]
IUD presenceIUD presence: The presence or absence of an intrauterine contraceptive device.
  • Present [An IUD is observed in the uterus.]
  • Absent [No IUD is observed in the uterus.]
  • Indeterminate [It is not possible to determine if an IUD is present or absent.]
IUD descriptionIUD description: Narrative description about an observed IUD in the uterus.
Other contributorsVebjørn Arntzen, Oslo University Hospital
Liv Laugen, Oslo University Hospital
Peter Fedorcsak, Oslo University Hospital
Translators
  • German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
  • Norwegian Bokmal: Peter Fedorcsak, Vebjørn Arntzen, Marit Alice Venheim, University of Oslo, Oslo University Hospital, Helse Vest IKT, peterfe@uio.no, varntzen@ous-hf.no, marit.alice.venheim@helse-vest-ikt.no