Modellbiblioteket openEHR Fork
Name
Imaging examination of a lymph node
Description
Findings observed in an imaging examination targeting a single lymph node, using radiographic techniques.
Purpose
To record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting a single lymph node.
Use
Use to record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting a single lymph node.
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 or site-specific findings.
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 or site-specific findings.
Misuse
Not 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 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.
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.
Archetype Id
openEHR-EHR-CLUSTER.imaging_exam-lymph_node.v0
Copyright
© openEHR Foundation
Licencing
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/.
Original Author
Heather Leslie
Atomica Informatics
Atomica Informatics
Date Originally Authored
To record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting a single lymph node.
Name | Card | Type | Description |
---|---|---|---|
Body structure
|
1..1 | DV_CODED_TEXT |
Identification of the body structure or region examined.
Constraint for DV_CODED_TEXT
|
Anatomical location
|
0..1 | DV_TEXT |
Simple body site for the identified structure.
Comment
If the anatomical location of the identified body structure is known, this data element is redundant.
|
Structured anatomical location
|
0..* | Slot (Cluster) |
Structured details about the anatomical location of the identified body structure.
Comment
If the anatomical location of the identified body structure is known or it has been identified in the 'Anatomical location' data element, this data element is redundant.
Slot
Slot
|
Imaging findings
|
0..1 | DV_TEXT |
Narrative description of the imaging findings observed during this examination.
|
SLOT: Additional details
|
0..* | Slot (Cluster) |
Additional structured details about imaging findings for the identified body structure or region, or findings for related substructures.
Slot
Slot
|
Impression
|
0..1 | DV_TEXT |
Narrative concise, clinically relevant impression of all imaging findings for the identified body structure.
Comment
Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate.
|
Comment
|
0..1 | DV_TEXT |
Additional narrative about the imaging findings, not captured in other fields.
|
Diameter
|
0..3 | DV_QUANTITY |
A measured diameter of the lymph node.
Comment
This data element has 3 occurrences to allow for measurements in 3 different axes.
DV_QUANTITY
|
archetype (adl_version=1.4; uid=e515a328-b219-4968-9162-75a51f951582) openEHR-EHR-CLUSTER.imaging_exam-lymph_node.v0 specialise openEHR-EHR-CLUSTER.imaging_exam.v0 concept [at0000.1] -- Imaging examination of a lymph node language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Heather Leslie"> ["organisation"] = <"Atomica Informatics"> ["email"] = <"heather.leslie@atomicainformatics.com"> ["date"] = <"2021-11-24"> > details = < ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting a single lymph node."> use = <"Use to record a narrative description, structured details and clinical impression of the findings observed in an imaging examination targeting a single lymph node. 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 or site-specific findings."> misuse = <"Not 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 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."> copyright = <"© openEHR Foundation"> > > lifecycle_state = <"in_development"> other_contributors = <"Vebjørn Arntzen, Oslo University Hospital", "Liv Laugen, Oslo University Hospital", "Peter Fedorcsak, Oslo University Hospital"> other_details = < ["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"] = <"openEHR Foundation"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"FB2BC5F6573A28397E1B6B789D5EE6EB"> ["build_uid"] = <"520851b6-ef12-4be2-a323-96063a431852"> ["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"> > definition CLUSTER[at0000.1] matches { -- Imaging examination of a lymph node items cardinality matches {1..*; unordered} matches { ELEMENT[at0001.1] matches { -- Body structure value matches { DV_CODED_TEXT matches { defining_code matches { [local::at0.1] -- Lymph node } } } } ELEMENT[at0002] occurrences matches {0..1} matches { -- Anatomical location value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0003] occurrences matches {0..*} matches { -- Structured anatomical location include archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v2|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0004] occurrences matches {0..1} matches { -- Imaging findings value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0005] occurrences matches {0..*} matches { -- SLOT: Additional details include archetype_id/value matches {/openEHR-EHR-CLUSTER\.imaging_finding(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.imaging_exam-abnormality(-[a-zA-Z0-9_]+)*\.v0/} } ELEMENT[at0006] occurrences matches {0..1} matches { -- Impression value matches { DV_TEXT matches {*} } } ELEMENT[at0007] occurrences matches {0..1} matches { -- Comment value matches { DV_TEXT matches {*} } } ELEMENT[at0.2] occurrences matches {0..3} matches { -- Diameter value matches { C_DV_QUANTITY < property = <[openehr::122]> list = < ["1"] = < units = <"mm"> magnitude = <|>=0.0|> precision = <|0|> > > > } } } } ontology terminologies_available = <"SNOMED-CT", ...> term_definitions = < ["en"] = < items = < ["at0000.1"] = < text = <"Imaging examination of a lymph node"> description = <"Findings observed in an imaging examination targeting a single lymph node, using radiographic techniques."> > ["at0001.1"] = < text = <"Body structure"> description = <"Identification of the body structure or region examined."> > ["at0.1"] = < text = <"Lymph node"> description = <"A single lymph node was examined."> > ["at0.2"] = < text = <"Diameter"> description = <"A measured diameter of the lymph node."> comment = <"This data element has 3 occurrences to allow for measurements in 3 different axes."> > ["at0000"] = < text = <"Imaging examination"> description = <"Findings observed in an imaging examination targeting a specified structure or region, using radiographic techniques."> > ["at0004"] = < text = <"Imaging findings"> description = <"Narrative description of the imaging findings observed during this examination."> > ["at0005"] = < text = <"SLOT: Additional details"> description = <"Additional structured details about imaging findings for the identified body structure or region, or findings for related substructures."> > ["at0007"] = < text = <"Comment"> description = <"Additional narrative about the imaging findings, not captured in other fields."> > ["at0001"] = < text = <"Body structure"> description = <"Identification of the body structure or region examined."> > ["at0003"] = < text = <"Structured anatomical location"> description = <"Structured details about the anatomical location of the identified body structure."> comment = <"If the anatomical location of the identified body structure is known or it has been identified in the 'Anatomical location' data element, this data element is redundant."> > ["at0006"] = < text = <"Impression"> description = <"Narrative concise, clinically relevant impression of all imaging findings for the identified body structure."> comment = <"Also referred to as 'Opinion'. May include a comparison with previous studies of the identified body structure, where appropriate."> > ["at0002"] = < text = <"Anatomical location"> description = <"Simple body site for the identified structure."> comment = <"If the anatomical location of the identified body structure is known, this data element is redundant."> > > > > term_bindings = < ["SNOMED-CT"] = < items = < ["at0.1"] = <[SNOMED-CT::59441001]> > > >