Examination of the fetus: Cluster
Requires Ocean Archetype Editor
Build 1.0.1236 or above 		Comments to Heather Leslie (Ocean)
What do the symbols mean? 		© Copyright openEHR Foundation 2007

Concept

Archetype Id

Structure
Examination cluster for describing a finding on physical examination of a fetus Id: openEHR-EHR-CLUSTER.exam-fetus.v1
Reference model: EHR
ADL, (ADL)

Cluster

 

Element

 
Examination of the fetus (specialisation of: Examination), Examination cluster for describing a finding on physical examination of a fetus.       Cluster (1..1) mandatory
 
Normal statements, A group of statements about the normality of the examination.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values
Normal statement A specific statement of normalityText
optional, repeating
0..*		 Free or coded text

Concept

Description

Type

Cardinality

Values
Clinical description Textural description of the part examinedText
optional
0..1		 Free or coded text
Findings, Clinical findings.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values
Lie of the fetus The position of the fetusCoded text
optional
0..1		 Longitudinal
Transverse
Oblique
Presentation The presenting part of the fetusCoded text
optional
0..1		 Cephalic
Breech
Full breech
Extended breech
Shoulder
Footling breech
Face
Cord
Compound
Position The orientation of the denominatorCoded text
optional
0..1		 Right Occipito-transverse
Right Occipito-anterior
Right Occipito-posterior
Occipito-anterior
Occipito-posterior
Left Occipito-transverse
Left Occipito-anterior
Left Occipito-posterior
Right Sacro-transverse
Right Sacro-anterior
Right Sacro-posterior
Sacro-Anterior
Sacro-Posterior
Left Sacro-transverse
Left Sacro-anterior
Left Sacro-posterior
Right Mento-transverse
Right Mento-anterior
Right Mento-posterior
Mento-Anterior
Mento-Posterior
Left Mento-transverse
Left Mento-anterior
Right Mento-posterior
Attitude The degree of flexion of the bodyCoded text
optional
0..1		 Flexed
Deflexed
Extended
Engagement, Estimation of presenting part in relation to pelvic brim.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values
Fifths The proportion of the presenting part which is felt above the pelvisCoded text
optional
0..1		 Not engaged (0/5)
1/5
2/5
3/5
4/5
Fully engaged (5/5)
Qualitative Description of engagement of fetal headCoded text
optional
0..1		 High and mobile
At pelvic brim
Engaged

Concept

Description

Type

Cardinality

Values
Size relative to gestation The apparent size of the baby relative to normal for gestationCoded text
optional
0..1		 Small for dates
? small for dates
Normal
? large for dates
Large for dates
Station Posiiton relative to the ischial spines (minus is above, 0 is at the spines and plus is below)Quantity
optional
0..1		 Property = LENGTH
Units:
   cm, -5..5 - Limit decimal places = 0
Estimated fetal weight The estimated weight of the baby on examinationQuantity
optional
0..1		 Property = MASS
Units:
   gm, 0..20000 - Limit decimal places = 0
   kg, 0..20
Size, Information about the size of the object for examination.       Cluster (0..1) optional
 

Slot

Type

Occurrences

Constraints
CLUSTER 0..* Include entries
Detail, More focused examination findings.       Cluster (0..1) optional
 

Slot

Type

Occurrences

Constraints
CLUSTER 0..* Include entries

Concept

Description

Type

Cardinality

Values
Image Drawing or image of the area examinedMultiMedia
optional, repeating
0..*		 image/gif
image/png
image/jpeg

Generated by the Ocean HTML generator: 13/04/2007