Examination of the uterus: 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
For recording findings of the uterus including when pregnant Id: openEHR-EHR-CLUSTER.exam-uterus.v1
Reference model: EHR
ADL, (ADL)

Cluster

 

Element

 
Examination of the uterus (specialisation of: Examination), For recording findings of the uterus including when pregnant.       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
Position Position of uterusCoded text
optional
0..1		 Anteverted
Retroverted
Size, Information about the size of the object for examination.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values
Fundal height The height of the uterine fundus measured from the symphysis pubisQuantity
optional
0..1		 Property = LENGTH
Units:
   cm, 0..100 - Limit decimal places = 1
Weeks of gestation The size in terms of weeks of pregnancyDuration
optional
0..1		 weeks
Relative to anatomical markers Relative size of uterus related to anatomy of personCoded text
optional
0..1		 At symphisis pubis
At umbilicus
At xiphisternum

Slot

Type

Occurrences

Constraints
CLUSTER 0..* Include entries

Concept

Description

Type

Cardinality

Values
Assessment of liquor volume The relative amount of liquor present in the uterusOrdinal
optional
0..1		 -3, Markedly reduced
-2, Reduced
-1, Slightly reduced
0, Normal
1, Slightly increased
2, Increased
3, Markedly increased
Number of fetuses The number of foetuses that are in the uterusCount
optional
0..1		 >= 0
Fetus, Information about one or more foetuses.       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

Slot

Type

Occurrences

Constraints
CLUSTER 0..* Include entries
Exclude entries:
  • openEHR-EHR-CLUSTER\..*

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