ARCHETYPE imaging_exam (openEHR-EHR-CLUSTER.imaging_exam-anomaly_copy.v0)

Use to record an incidental or ambiguous finding of a single anomaly on radiological examination that deviates from what is expected or normal within an identified body structure or region.

If more than one anomaly has been identified within the context of the same body structure or region, use a separate instance of this archetype to describe each anomaly.

The intended scope for this archetype is to record detailed findings about an anomaly using any modality. It is anticipated that specific CLUSTER archetypes will be developed in the future to record common abnormal radiological findings, such as fractures. If a specific archetype to record the anomaly is not available, use this generic archetype to record relevant findings.

Until the specific archetypes are developed, current use cases include, but are not limited to:

• a large, mixed solid/cystic lesion containing teeth and hair, identified within the ovary - for example, a dermoid cyst;
• a solid mass identified within the right upper lobe of the lung - for example, a past infection scar or a tumour;
• a calcified lesion identified within the left kidney - for example, a kidney calculus; or
• a soft tissue mass identified within the heart - for example, a thrombosis.

This archetype is designed to be nested within the 'Additional details' SLOT in any of the CLUSTER.imaging_exam family of archetypes which will provide the context for the anomaly, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate.

• Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
• Custodian Organisation: Ocean Informatics
• Original Namespace: com.oceaninformatics
• Original Publisher: Ocean Informatics
• Custodian Namespace: com.oceaninformatics
• MD5-CAM-1.0.1: AD5D908EE4785E42DC508A2F979A2747
• Build Uid: ba2114fe-ae72-4e3a-b963-f33478509a6d
• 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

• >=0.0 mm
• >=0.0 cm

• at0.26::Length [The measured length of the longest edge or aspect of the anomaly.]
• at0.27::Width [The measured length of widest aspect of the anomaly, usually perpendicular to the length or the measured length of the second side of two sides.]
• at0.28::Height [The measured length of the vertical aspect of the anomaly, from the base to the top.]
• at0.29::Depth [The measured length of the third aspect of the anomaly, usually perpendicular to the length and width or measurement of the vertical aspect of the anomaly from the surface to the base. May also known as thickness.]
• at0.30::Diameter [The measured length of the anomaly from edge to edge, usually of an approximately round or oval anomaly, passing through its centre.]

• at0.17::Present [Calcification is observed.]
• at0.18::Absent [Calcification is not observed.]

• German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
• Norwegian Bokmal: Peter Fedorcsak, Vebjørn Arntzen, University of Oslo, Oslo University Hospital, peterfe@uio.no, varntzen@ous-hf.no