Modellbiblioteket openEHR Fork
Name
Imaging examination of the rectouterine pouch
Description
Findings on radiological examination of the rectouterine pouch.
Keywords
Rectovaginal Douglas pouch cul-de-sac
Purpose
To record the findings on radiological examination of the rectouterine pouch, and their interpretation.
Use
Use to record the findings on radiological examination of the rectouterine pouch, and their interpretation.

The intended scope for this archetype is to eventually record all detailed findings on radiological examination of the rectouterine pouch using any modality. It is anticipated that further data elements may be added as requirements are identified and confirmed.

This archetype is designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result or within other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype needs to be extended with further levels of structured findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT.
Misuse
Not to be used to record imaging examination findings for any body structure or region other than the rectouterine pouch. 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.
References
Verguts, J., Timmerman, D., Bourne, T., Lewi, P. and Koninckx, P. (2010), Accuracy of peritoneal fluid measurements by transvaginal ultrasonography. Ultrasound Obstet Gynecol, 35: 589-592. Available from: https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.7632.
Archetype Id
openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v1
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
Date Originally Authored
2021-11-24
Language Details
German
Natalia Strauch
Medizinische Hochschule Hannover
Norwegian Bokmal
Peter Fedorcsak, Vebjørn Arntzen
University of Oslo, Oslo University Hospital
Name Card Type Description
Body structure
1..1 DV_CODED_TEXT Identification of the body structure or region examined.
Comment
If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT becomes redundant.
Constraint for DV_CODED_TEXT
  • Rectouterine pouch
Body site
0..1 DV_TEXT Identification of the area of the body under examination.
Comment
For example: a lymph node group (body structure) which found in the 'Right axilla'. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable. If the body site has been fully identified in the 'Body structure' data element, this data element becomes redundant.
Structured body site
0..* Slot (Cluster) Structured details about the area of the body under examination.
Comment
For example: details about a relative anatomical location, such as '2cm distal to the appendix'. If the body site has been fully identified in the 'Body structure' or 'Body site' data elements, then this SLOT becomes redundant.
Slot
Slot
Imaging findings
0..1 DV_TEXT Narrative description of the imaging findings observed during this examination.
Additional details
0..* Slot (Cluster) Additional structured details about imaging findings for the identified body structure or region, or findings of related structures.
Slot
Slot
Impression
0..* DV_TEXT Single word, phrase or brief description that represents the clinical meaning and significance of all imaging findings for the identified body structure.
Comment
Also referred to as 'Interpretation' or 'Opinion'. For example: 'No abnormality detected' or 'Free fluid present'. Coding of the 'Impression' with a terminology is permitted, if useful. Multiple occurrences allow for more than one coded impression. A narrative description may include a comparison with previous studies of the identified body structure, if appropriate.
Comment
0..1 DV_TEXT Additional narrative about the imaging findings of the body structure, not captured in other fields.
Fluid presence
0..1 DV_CODED_TEXT Observation of the presence of free fluid.
Constraint for DV_CODED_TEXT
  • Present
    [Free fluid is observed in the rectouterine pouch.]
  • Absent
    [No free fluid is observed in the rectouterine pouch.]
Diameter
0..3 DV_QUANTITY A measured diameter of the recto-uterine pouch.
Comment
This data element has 3 occurrences to allow for measurements in 3 different axes.
DV_QUANTITY
Amount of free fluid
0..1
CHOICE OF
DV_CODED_TEXT
DV_QUANTITY
The amount of fluid observed.
Constraint for DV_CODED_TEXT
  • Small
  • Medium
  • Large
DV_QUANTITY
archetype (adl_version=1.4; uid=fecbe690-a3c8-4698-9ac0-11be49e2123d)
	openEHR-EHR-CLUSTER.imaging_exam-rectouterine_pouch.v1
specialise
	openEHR-EHR-CLUSTER.imaging_exam.v1

concept
	[at0000.1]	-- Imaging examination of the rectouterine pouch
language
	original_language = <[ISO_639-1::en]>
	translations = <
		["de"] = <
			language = <[ISO_639-1::de]>
			author = <
				["name"] = <"Natalia Strauch">
				["organisation"] = <"Medizinische Hochschule Hannover">
				["email"] = <"Strauch.Natalia@mh-hannover.de">
			>
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			author = <
				["name"] = <"Peter Fedorcsak, Vebjørn Arntzen">
				["organisation"] = <"University of Oslo, Oslo University Hospital">
				["email"] = <"peterfe@uio.no, varntzen@ous-hf.no">
			>
		>
	>
description
	original_author = <
		["name"] = <"Heather Leslie">
		["organisation"] = <"Atomica Informatics">
		["email"] = <"heather.leslie@atomicainformatics.com">
		["date"] = <"2021-11-24">
	>
	details = <
		["de"] = <
			language = <[ISO_639-1::de]>
			purpose = <"*To record the findings on radiological examination of the rectouterine pouch, and their interpretation. (en)">
			use = <"*Use to record the findings on radiological examination of the rectouterine pouch, and their interpretation.

The intended scope for this archetype is to eventually record all detailed findings on radiological examination of the rectouterine pouch using any modality. It is anticipated that further data elements may be added as requirements are identified and confirmed.

This archetype is designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype needs to be extended with further levels of structured findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT. (en)">
			keywords = <"*Rectovaginal, Douglas, pouch, cul-de-sac (en)", ...>
			misuse = <"*Not to be used to record imaging examination findings for any body structure or region other than the rectouterine pouch. 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. (en)">
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			purpose = <"For å registrere funn ved radiologisk undersøkelse av fossa Douglasi og tolkning av dem.">
			use = <"Brukes for å registrere funn ved radiologisk undersøkelse av fossa Douglasi og tolkning av dem.

Det tiltenkte omfanget for denne CLUSTER.imaging_exam (Bildediagnostisk undersøkelse) - arketypen er til slutt å kunne registrere alle detaljerte funn ved bildediagnostisk undersøkelse av fossa Douglasi uavhengig av modalitet. Det er forventet at flere dataelementer kan bli lagt til når krav til slike er identifisert og bekreftet.

Denne arketypen er utformet for å bli nøstet i SLOT'et \"Ytterligere detaljer\" i SLOT'et \"Strukturerte funn\" i OBSERVATION.imaging_exam_result (Bildediagnostisk svar) eller i andre relevante CLUSTER.imaging_exam-arketyper, i men kan også brukes innen andre ENTRY- og CLUSTER-arketyper der det er klinisk passende. Hvis denne arketypen, eller en spesialisering av denne, må utvides med flere nivåer med detaljerte funn eller observasjoner, kan flere forekomster av arketypen eller dens spesialiseringer nøstes i SLOT'et \"Ytterligere detaljer\".">
			keywords = <"Rectovaginal", "Douglas", "grop", "cul-de-sac", "recto-uterin">
			misuse = <"Skal ikke brukes til å registrere funn fra undersøkelser av andre kroppsstrukturer enn fossa Douglasi. Bruk andre arketyper fra gruppen av CLUSTER.imaging_exam-arketyper for dette.

Skal ikke brukes til å registrere overordnede undersøkelsesfunn, kontekst eller tekniske detaljer relatert til et fullstendig svar på billedundersøkelsen. Bruk arketypen OBSERVATION.imaging_exam_result (Bildediagnostisk svar) for å registrere dette, for eksempel kommentar om undersøkelseskvalitet, differensialdiagnose og overordnet konklusjon.">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To record the findings on radiological examination of the rectouterine pouch, and their interpretation.">
			use = <"Use to record the findings on radiological examination of the rectouterine pouch, and their interpretation.

The intended scope for this archetype is to eventually record all detailed findings on radiological examination of the rectouterine pouch using any modality. It is anticipated that further data elements may be added as requirements are identified and confirmed.

This archetype is designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result or within other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype needs to be extended with further levels of structured findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT.">
			keywords = <"Rectovaginal, Douglas, pouch, cul-de-sac", ...>
			misuse = <"Not to be used to record imaging examination findings for any body structure or region other than the rectouterine pouch. 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 = <"published">
	other_contributors = <"Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør)", "Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor)", "Silje Ljosland Bakke, Helse Vest IKT AS, Norway (openEHR Editor)", "SB Bhattacharyya, Bhattacharyyas Clinical Records Research & Informatics LLP, India", "Randi Brendberg, Helse Nord RHF, Norway", "Peter Fedorcsak, University of Oslo, Norway (openEHR Editor)", "Heather Grain, Llewelyn Grain Informatics, Australia", "Anca Heyd, DIPS ASA, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør)", "Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør)", "Liv Laugen, ​Oslo University Hospital, Norway, Norway (openEHR Editor)", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør)", "Mikael Nyström, Cambio Healthcare Systems AB, Sweden", "Norwegian Review Summary, Norwegian Public Hospitals, Norway", "Tina Tellum, Oslo Universitetssykehus, Norway", "Anders Thurin, VGR, Sweden", "John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)", "Ina Wille, Helse-Vest RHF, Norway">
	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">
		["references"] = <"Verguts, J., Timmerman, D., Bourne, T., Lewi, P. and Koninckx, P. (2010), Accuracy of peritoneal fluid measurements by transvaginal ultrasonography. Ultrasound Obstet Gynecol, 35: 589-592. Available from: https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.7632.">
		["original_namespace"] = <"org.openehr">
		["original_publisher"] = <"openEHR Foundation">
		["custodian_namespace"] = <"org.openehr">
		["MD5-CAM-1.0.1"] = <"5DA67A9F228E88D6F28A92D7F8FD1337">
		["build_uid"] = <"fa2be034-c8e7-4841-977c-5f2709a90c0f">
		["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"] = <"1.0.0">
	>

definition
	CLUSTER[at0000.1] matches {    -- Imaging examination of the rectouterine pouch
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0001.1] matches {    -- Body structure
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::at0.1]    -- Rectouterine pouch
						}
					}
				}
			}
			ELEMENT[at0002] occurrences matches {0..1} matches {    -- Body site
				value matches {
					DV_TEXT matches {*}
				}
			}
			allow_archetype CLUSTER[at0003] occurrences matches {0..*} matches {    -- Structured body site
				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 {    -- Additional details
				include
					archetype_id/value matches {/openEHR-EHR-CLUSTER\.imaging_exam-lymph_node(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.imaging_exam-lymph_node_group(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.imaging_exam-lesion(-[a-zA-Z0-9_]+)*\.v0/}
			}
			ELEMENT[at0006] occurrences matches {0..*} 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..1} matches {    -- Fluid presence
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.3,    -- Present
							at0.4]    -- Absent
						}
					}
				}
			}
			ELEMENT[at0.9] occurrences matches {0..3} matches {    -- Diameter
				value matches {
					C_DV_QUANTITY <
						property = <[openehr::122]>
						list = <
							["1"] = <
								units = <"mm">
								magnitude = <|>=0.0|>
							>
							["2"] = <
								units = <"cm">
								magnitude = <|>=0.0|>
							>
						>
					>
				}
			}
			ELEMENT[at0.5] occurrences matches {0..1} matches {    -- Amount of free fluid
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.6,    -- Small
							at0.7,    -- Medium
							at0.8]    -- Large
						}
					}
					C_DV_QUANTITY <
						property = <[openehr::129]>
						list = <
							["1"] = <
								units = <"L">
								magnitude = <|>=0.0|>
							>
							["2"] = <
								units = <"mL">
								magnitude = <|>=0.0|>
							>
						>
					>
				}
			}
		}
	}


ontology
	terminologies_available = <"SNOMED-CT", ...>
	term_definitions = <
		["en"] = <
			items = <
				["at0.1"] = <
					text = <"Rectouterine pouch">
					description = <"">
				>
				["at0.2"] = <
					text = <"Fluid presence">
					description = <"Observation of the presence of free fluid.">
				>
				["at0.3"] = <
					text = <"Present">
					description = <"Free fluid is observed in the rectouterine pouch.">
				>
				["at0.4"] = <
					text = <"Absent">
					description = <"No free fluid is observed in the rectouterine pouch.">
				>
				["at0.5"] = <
					text = <"Amount of free fluid">
					description = <"The amount of fluid observed.">
				>
				["at0.6"] = <
					text = <"Small">
					description = <"">
				>
				["at0.7"] = <
					text = <"Medium">
					description = <"">
				>
				["at0.8"] = <
					text = <"Large">
					description = <"">
				>
				["at0.9"] = <
					text = <"Diameter">
					description = <"A measured diameter of the recto-uterine pouch.">
					comment = <"This data element has 3 occurrences to allow for measurements in 3 different axes.">
				>
				["at0000"] = <
					text = <"Imaging examination of a body structure">
					description = <"Findings on radiological examination of a specified body structure or region.">
				>
				["at0000.1"] = <
					text = <"Imaging examination of the rectouterine pouch">
					description = <"Findings on radiological examination of the rectouterine pouch.">
				>
				["at0001"] = <
					text = <"Body structure">
					description = <"Identification of the body structure or region examined.">
					comment = <"For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant.">
				>
				["at0001.1"] = <
					text = <"Body structure">
					description = <"Identification of the body structure or region examined.">
					comment = <"If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT becomes redundant.">
				>
				["at0002"] = <
					text = <"Body site">
					description = <"Identification of the area of the body under examination.">
					comment = <"For example: a lymph node group (body structure) which found in the 'Right axilla'. Coding of 'Body site' with a terminology, such as SNOMED CT, is desirable. If the body site has been fully identified in the 'Body structure' data element, this data element becomes redundant.">
				>
				["at0003"] = <
					text = <"Structured body site">
					description = <"Structured details about the area of the body under examination.">
					comment = <"For example: details about a relative anatomical location, such as '2cm distal to the appendix'. If the body site has been fully identified in the 'Body structure' or 'Body site' data elements, then this SLOT becomes redundant.">
				>
				["at0004"] = <
					text = <"Imaging findings">
					description = <"Narrative description of the imaging findings observed during this examination.">
				>
				["at0005"] = <
					text = <"Additional details">
					description = <"Additional structured details about imaging findings for the identified body structure or region, or findings of related structures.">
				>
				["at0006"] = <
					text = <"Impression">
					description = <"Single word, phrase or brief description that represents the clinical meaning and significance of all imaging findings for the identified body structure.">
					comment = <"Also referred to as 'Interpretation' or 'Opinion'. For example: 'No abnormality detected' or 'Free fluid present'. Coding of the 'Impression' with a terminology is permitted, if useful. Multiple occurrences allow for more than one coded impression. A narrative description may include a comparison with previous studies of the identified body structure, if appropriate.">
				>
				["at0007"] = <
					text = <"Comment">
					description = <"Additional narrative about the imaging findings of the body structure, not captured in other fields.">
				>
			>
		>
		["nb"] = <
			items = <
				["at0.1"] = <
					text = <"Fossa Douglasi">
					description = <"">
				>
				["at0.2"] = <
					text = <"Tilstedeværelse av fri væske">
					description = <"Observasjon om det er fri væske tilstede eller ikke.">
				>
				["at0.3"] = <
					text = <"Tilstede">
					description = <"Fri væske er sett i fossa Douglasi.">
				>
				["at0.4"] = <
					text = <"Ikke tilstede">
					description = <"Ingen fri væske er sett i fossa Douglasi.">
				>
				["at0.5"] = <
					text = <"Mengde fri væske">
					description = <"Mengden av fri væske sett.">
				>
				["at0.6"] = <
					text = <"Liten">
					description = <"">
				>
				["at0.7"] = <
					text = <"Middels">
					description = <"">
				>
				["at0.8"] = <
					text = <"Stor">
					description = <"">
				>
				["at0.9"] = <
					text = <"Diameter">
					description = <"Målt diameter av fri væske i fossa Douglasi.">
					comment = <"Elementet har 3 forekomster for å tillate registrering av målinger i 3 retninger.">
				>
				["at0000"] = <
					text = <"Bildediagnostisk undersøkelse - kroppsstruktur">
					description = <"Funn eller observasjoner ved radiologisk undersøkelse av et definert organ eller en kroppsdel.">
				>
				["at0000.1"] = <
					text = <"Bildediagnostisk undersøkelse - fossa Douglasi">
					description = <"Funn ved bildediagnostisk undersøkelse av fossa Douglasi med bruk av radiologiske metoder.">
				>
				["at0001"] = <
					text = <"Kroppsstruktur">
					description = <"Identifisering av organet eller kroppsdelen som svaret gjelder.">
					comment = <"For eksempel \"Lever\", \"Høyre ankel\" eller \"Lymfeknutegruppe\". Det er anbefalt å kode kroppsstruktur med en passende terminologi, som SNOMED CT. Dersom den aktuelle strukturen i kroppen er fullt ut angitt i dette \"Kroppsstruktur\"-elementet er det ikke nødvendig å bruke \"Anatomisk lokalisasjon\" eller \"Strukturert anatomisk lokalisasjon\".">
				>
				["at0001.1"] = <
					text = <"Kroppsstruktur">
					description = <"Identifisering av strukturen i kroppen eller regionen som er undersøkt.">
					comment = <"Dersom den aktuelle strukturen i kroppen er fullt ut angitt i dette \"Kroppsstruktur\"-elementet er det ikke nødvendig å bruke \"Anatomisk lokalisasjon\" eller \"Strukturert anatomisk lokalisasjon\".">
				>
				["at0002"] = <
					text = <"Anatomisk lokalisasjon">
					description = <"Identifisering av organ eller kroppsdel.">
					comment = <"For eksempel en lymfeknutegruppe (Kroppsstruktur) som er funnet i \"Høyre aksille\" (Anatomisk lokalisasjon). Det er ønskelig å kode \"Anatomisk lokalisasjon\" med en terminologi, som SNOMED CT. Dersom den anatomiske lokalisasjonen er fullt ut angitt i elementet \"Kroppsstruktur\" er det ikke nødvendig å bruke \"Anatomisk lokalisasjon\".">
				>
				["at0003"] = <
					text = <"Strukturert anatomisk lokalisasjon">
					description = <"Strukturerte detaljer om organ eller kroppsdel.">
					comment = <"For eksempel detaljert om en relativ anatomisk lokalisasjon, som \"2 cm distalt for appendix\". Dersom den nøyaktige eller relative anatomiske lokalisasjonen er fullt ut angitt i elementet \"Kroppsstruktur\" er det ikke nødvendig å bruke \"Strukturert anatomisk lokalisasjon\".">
				>
				["at0004"] = <
					text = <"Funn">
					description = <"Fritekstlig beskrivelse av funn eller observasjoner på bilder tatt under denne undersøkelsen.">
				>
				["at0005"] = <
					text = <"Ytterligere detaljer">
					description = <"Ytterligere strukturerte detaljer om funn eller observasjoner på bilder for det definerte organet eller kroppsdelen, eller om funn eller observasjoner hos tilhørende kroppsstrukturer.">
				>
				["at0006"] = <
					text = <"Resymé">
					description = <"Enkeltord, frase eller kortfattet beskrivelse som uttrykker den kliniske betydningen av alle funn og observasjoner for den definerte kroppsstrukturen.">
					comment = <"Kan også kalles \"Tolkning\" eller \"Inntrykk\". For eksempel \"Uten anmerkning\" eller \"Fri væske\". Dersom det er nyttig, er det åpent for å kode \"Resymé\" med en terminologi. Flere svar kan kodes ved at elementet er åpent for å være gjentakende. En beskrivelse i fritektst kan også brukes og kan inneholde en sammenligning med tidligere undersøkelser av samme kroppsstruktur.">
				>
				["at0007"] = <
					text = <"Kommentar">
					description = <"Ytterligere fritekst om funn eller observasjoner på bilder av kroppsstrukturen og som ikke er fanget i andre felt.">
				>
			>
		>
		["de"] = <
			items = <
				["at0000.1"] = <
					text = <"Bildgebende Untersuchung einer Körperstruktur">
					description = <"*Findings on radiological examination of the rectouterine pouch. (en)">
				>
				["at0001.1"] = <
					text = <"Körperstruktur">
					description = <"Identifizierung der untersuchten Körperstruktur oder Region.">
					comment = <"*If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT becomes redundant. (en)">
				>
				["at0.1"] = <
					text = <"Rectouterine pouch">
					description = <"">
				>
				["at0.2"] = <
					text = <"Fluid presence">
					description = <"*Observation of the presence of free fluid. (en)">
				>
				["at0.3"] = <
					text = <"Present">
					description = <"Free fluid is observed in the rectouterine pouch.">
				>
				["at0.4"] = <
					text = <"Absent">
					description = <"No free fluid is observed in the rectouterine pouch.">
				>
				["at0.5"] = <
					text = <"Amount of free fluid">
					description = <"The amount of fluid observed.">
				>
				["at0.6"] = <
					text = <"Small">
					description = <"">
				>
				["at0.7"] = <
					text = <"Medium">
					description = <"">
				>
				["at0.8"] = <
					text = <"Large">
					description = <"">
				>
				["at0.9"] = <
					text = <"Diameter">
					description = <"A measured diameter of the recto-uterine pouch.">
					comment = <"This data element has 3 occurrences to allow for measurements in 3 different axes.">
				>
				["at0000"] = <
					text = <"Bildgebende Untersuchung einer Körperstruktur">
					description = <"Befunde zur radiologischen Untersuchung einer bestimmten Körperstruktur oder -region.">
				>
				["at0001"] = <
					text = <"Körperstruktur">
					description = <"Identifizierung der untersuchten Körperstruktur oder Region.">
					comment = <"*For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. If the body structure has been fully identified in this 'Body structure' element, then the 'Body site' data element and 'Structured body site' SLOT become redundant. (en)">
				>
				["at0002"] = <
					text = <"Körperstelle">
					description = <"Identifizierung des zu untersuchenden Bereichs des Körpers.">
					comment = <"Zum Beispiel: eine Lymphknotengruppe (Körperstruktur), die sich in der „rechten Achselhöhle“ befindet. Eine Kodierung von „Körperstelle“ mit einer Terminologie, wie z. B. SNOMED CT, ist wünschenswert. Wenn die Körperstelle im Datenelement „Körperstruktur“ vollständig identifiziert wurde, wird dieses Datenelement überflüssig.">
				>
				["at0003"] = <
					text = <"Körperstelle strukturiert">
					description = <"Strukturierte Angaben zum untersuchten Körperbereich.">
					comment = <"Zum Beispiel: Angaben zu einer relativen anatomischen Lokalisation, wie z. B. „2 cm distal zum Blinddarm“. Wenn die Körperstelle in den Datenelementen „Körperstruktur“ oder „Körperstelle“ vollständig identifiziert wurde, wird dieser SLOT überflüssig.">
				>
				["at0004"] = <
					text = <"Bildgebende Befunde">
					description = <"Beschreibung der bei dieser Untersuchung beobachteten bildgebenden Befunde.">
				>
				["at0005"] = <
					text = <"Zusätzliche Angaben">
					description = <"Zusätzliche strukturierte Angaben zu bildgebenden Befunden für die identifizierte Körperstruktur oder -region oder befundbezogene Strukturen.">
				>
				["at0006"] = <
					text = <"Interpretation">
					description = <"Einzelnes Wort, Satz oder kurze Beschreibung, die die klinische Bedeutung und Signifikanz aller bildgebenden Befunde für die identifizierte Körperstruktur darstellt.">
					comment = <"Auch als „Eindruck“ oder „Meinung“ bezeichnet. Zum Beispiel: „Keine Anomalie erkannt“ oder „Freie Flüssigkeit vorhanden“. Eine Kodierung des „Interpretation“ mit einer Terminologie ist zulässig, sofern sinnvoll. Mehrere Vorkommen ermöglichen mehr als eine codierte Interpretation. Eine einfache Beschreibung kann gegebenenfalls einen Vergleich mit früheren Studien der identifizierten Körperstruktur beinhalten.">
				>
				["at0007"] = <
					text = <"Kommentar">
					description = <"Zusätzlicher Text über die bildgebenden Befunde der Körperstruktur, der in anderen Bereichen nicht erfasst wurde.">
				>
			>
		>
	>
	term_bindings = <
		["SNOMED-CT"] = <
			items = <
				["at0.1"] = <[SNOMED-CT::53843000]>
			>
		>
	>