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
Copyrightcopyright (c) 2010 openEHR Foundation
AuthorsAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 08/04/2007
Other Details LanguageAuthor name: Sam Heard
Organisation: Ocean Informatics
Email: sam.heard@oceaninformatics.com
Date originally authored: 08/04/2007
OtherDetails Language Independent{references=, MD5-CAM-1.0.1=8DC03436AB8E13BDA1F013485E53C77E}
Keywordsexamination, physical, uterus, pregnancy
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.230
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=For recording findings of the uterus including when pregnant., archetypeConceptComment=null, otherContributors=, originalLanguage=en, translators=, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={source=[], provider=[], ism_transition=[], other_participations=[], activities=[], protocol=[], content=[], state=[], description=[], identities=[], data=[], credentials=[], target=[], capabilities=[], 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=Optional, 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=Optional, repeating, 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=Optional, 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=Optional, 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=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations Or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations, 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=Optional, 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=Optional, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • 0.0..100.0 cm
    Limit decimal places: 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: weeks

, 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=Optional, 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=Optional, 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=Optional, 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=Optional, 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=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=image/gif, image/png, image/jpeg, extendedValues=null]], contacts=[], relationships=[], context=[], events=[], details=[]}, topLevelItems={items=ResourceSimplifiedHierarchyItem [path=ROOT_/, code=at0000.1, 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[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=Optional, 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=Optional, repeating, 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=Optional, 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=Optional, 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=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations Or
openEHR-EHR-CLUSTER.palpation.v1 and specialisations, 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=Optional, 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=Optional, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_QUANTITY, bindings=null, values=Property: Length
Units:
  • 0.0..100.0 cm
    Limit decimal places: 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.physical_properties.v1 and specialisations, 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=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=Allowed values: weeks

, 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=Optional, 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=Optional, 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=Optional, 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=Optional, 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=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
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=Optional, repeating, 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]