| ARCHETYPE ID | openEHR-EHR-CLUSTER.exam-uterus.v1 |
|---|---|
| Concept | Examination of the uterus |
| Description | For recording findings of the uterus including when pregnant. |
| Purpose | A cluster for recording findings on physical examination of the uterus. |
| References | |
| Copyright | copyright (c) 2010 openEHR Foundation |
| Authors | Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 08/04/2007 |
| Other Details Language | Author name: Sam Heard Organisation: Ocean Informatics Email: sam.heard@oceaninformatics.com Date originally authored: 08/04/2007 |
| Other Details (Language Independent) |
|
| Keywords | examination, physical, uterus, pregnancy |
| Lifecycle | AuthorDraft |
| Language used | en |
| Citeable Identifier | 1013.1.230 |
| 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. |
| Detail | Detail: More focused examination findings Include: openEHR-EHR-CLUSTER.exam-generic.v1 and specialisations or openEHR-EHR-CLUSTER.palpation.v1 and specialisations |
| Position | Position: Position of uterus.
|
| Size | Size: Information about the size of the object for examination. |
| Fundal height | Fundal height: The height of the uterine fundus measured from the symphysis pubis. Property: Length Units: 0.0..100.0 cm Limit decimal places: 1 |
| Size | Size: Details of uterine size. Include: openEHR-EHR-CLUSTER.physical_ |
| Weeks of gestation | Weeks of gestation: The size in terms of weeks of pregnancy. Allowed values: weeks |
| Relative to anatomical markers | Relative to anatomical markers: Relative size of uterus related to anatomy of person.
|
| Assessment of liquor volume | Assessment of liquor volume: The relative amount of liquor present in the uterus. -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.] |
| Number of fetuses | Number of fetuses: The number of foetuses that are in the uterus. min: >=0 |
| Fetus | Fetus: Information about one or more foetuses. |
| Fetal detail | Fetal detail: Detailed information about one or more foetuses. Include: openEHR-EHR-CLUSTER.exam-fetus.v1 |
| Image | Image: Drawing or image of the area examined. image/gif, image/png, image/jpeg |
| Other contributors | |
| Translators |