archetype (adl_version=1.4; uid=32209bd7-2307-4a15-8009-e32ff69ea895)
	openEHR-EHR-CLUSTER.imaging_exam-spine.v0
specialise
	openEHR-EHR-CLUSTER.imaging_exam.v1

concept
	[at0000.1]	-- Imaging examination of the entire spine
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"] = <"Vebjørn Arntzen, John Tore Valand">
				["organisation"] = <"Oslo University Hospital, Helse Bergen">
				["email"] = <"varntzen@ous-hf.no, john.tore.valand@helse-vest-ikt.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 entire spine, and their interpretation. (en)">
			use = <"*Use to record the findings on radiological examinations that cover the entire spine, and their interpretation.

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

This archetype and its related family of specialisations are designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result or within the 'Additional details' SLOT in other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype or its specialisations need to be extended with further levels of detailed findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT.

 (en)">
			keywords = <"Befund, Ergebnis, Bildgebung, Körper, Organ, System, Struktur, Region, Beobachtung, Diagnostik, Radiologie, Bild", ...>
			misuse = <"*Not to be used to record imaging examination findings for any body structure or region other than the entire spine. Examinations on specific areas of the spine is to be record using other archetypes from the CLUSTER.imaging_exam family for this purpose. For example: CLUSTER.imaging_exam-cervical_spine or CLUSTER.imaging_exam-sacrum.

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 OBSERVATION.imaging_exam_result for this purpose. For example, comments on the study quality, differential diagnoses, and overall impression. (en)">
			copyright = <"© openEHR Foundation">
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			purpose = <"For å registrere funn eller observasjoner ved radiologisk undersøkelse av hele ryggraden.">
			use = <"Bruk for å registrere funn og klinisk tolkning ved bildediagnostisk undersøkelse av hele ryggraden.

Det tiltenkte omfanget for denne CLUSTER.imaging_exam (Bildediagnostisk undersøkelse) - arketypen er til slutt å kunne registrere alle detaljerte funn ved bildediagnostisk undersøkelse av pelvis 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 Bildediagnostisk svar-arketyper, 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 = <"funn", "observasjon", "bildediagnostikk", "kropp", "organ", "kroppsstruktur", "diagnostisk", "radiologi", "bilde">
			misuse = <"Skal ikke brukes til å registrere funn som er gjort utenom det definerte organet eller den definerte kroppsdelen. Bruk en egen instans av en eller flere arketyper innen gruppen av CLUSTER.imaging_exam - arketyper (Undersøkelsesfunn) for dette formålet.

Skal ikke brukes til å registrere overordnede undersøkelsesfunn, kontekst eller tekniske detaljer relatert til bildeundersøkelsen. Bruk arketypen OBSERVATION.imaging_exam_result (Bildediagnostisk svar) for å registrere for eksempel kommentar om undersøkelseskvalitet, differensialdiagnose og overordnet konklusjon.">
			copyright = <"© openEHR Foundation">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To record the findings on radiological examination of the entire spine, and their interpretation.">
			use = <"Use to record the findings on radiological examinations that cover the entire spine, and their interpretation.

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

This archetype and its related family of specialisations are designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result or within the 'Additional details' SLOT in other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype or its specialisations need to be extended with further levels of detailed findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT.">
			keywords = <"finding, imaging, body, system, structure, region, observation, diagnostic, radiology, image", ...>
			misuse = <"Not to be used to record imaging examination findings for any body structure or region other than the entire spine. Examinations on specific areas of the spine is to be record using other archetypes from the CLUSTER.imaging_exam family for this purpose. For example: CLUSTER.imaging_exam-cervical_spine or CLUSTER.imaging_exam-sacrum.

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 OBSERVATION.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 = <"Andreas Abildgaard, OUS, Norway", "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", "Gunn Elin Blakkisrud, DIPS ASA, Norway", "Peter Fedorcsak, University of Oslo, Norway (openEHR Editor)", "Kåre Flø, DIPS ASA, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Kija Indrearne, Helse Bergen, Norway", "Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør)", "Aud Jorunn Mjelstad, Helse Bergen, Norway", "Anjali Kulkarni, Karkinos, India", "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)", "Svenne Naumann, Finnmarkssykehuset, Norway", "Mikael Nyström, Cambio Healthcare Systems AB, Sweden", "Bjørn Næss, DIPS ASA, Norway", "Natalia Strauch, Medizinische Hochschule Hannover, Germany", "Norwegian Review Summary, Norwegian Public Hospitals, Norway", "John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)">
	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"] = <"https://radiopaedia.org/articles/sagittal-balance

https:///www.ncbi.nlm.nih.gov/books/NBK534858

https://unn.no/Documents/Kvalitetsregistre/Nasjonalt%20kvalitetsregister%20for%20ryggkirurgi/Brukermanualer/Praktisk%20veileder%20og%20Brukermanual%20ryggregisteret_V3.0_190529.pdf">
		["original_namespace"] = <"org.openehr">
		["original_publisher"] = <"openEHR Foundation">
		["custodian_namespace"] = <"org.openehr">
		["MD5-CAM-1.0.1"] = <"0715FC75BDEED95C50F7053A93B1B484">
		["build_uid"] = <"8876d267-4bd7-46fa-8f01-0a5e614e87b6">
		["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 the entire spine
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0001.1] matches {    -- Body structure
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::at0.6]    -- Spine
						}
					}
				}
			}
			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[at0.1] occurrences matches {0..1} matches {    -- Sagittal vertical axis
				value matches {
					C_DV_QUANTITY <
						property = <[openehr::122]>
						list = <
							["1"] = <
								units = <"cm">
							>
						>
					>
				}
			}
			ELEMENT[at0.2] occurrences matches {0..1} matches {    -- C7 Plumb Line
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.3,    -- Positive
							at0.4,    -- Neutral
							at0.5]    -- Negative
						}
					}
				}
			}
		}
	}


ontology
	terminologies_available = <"SNOMED-CT", ...>
	term_definitions = <
		["en"] = <
			items = <
				["at0.1"] = <
					text = <"Sagittal vertical axis">
					description = <"The measured length of a horizontal line connecting the posterior superior sacral endplate with a vertical plumb line from C7.">
					comment = <"Positive values express that the vertical plumb line lies anterior to the posteosuperior corner of S1. Negative values express that the plumb line lies posteriorly.">
				>
				["at0.2"] = <
					text = <"C7 Plumb Line">
					description = <"The vertical line drawn from the center of the C7 vertebral body in a caudal direction.">
				>
				["at0.3"] = <
					text = <"Positive">
					description = <"The plumb line passes more than 2 cm in front of the posterosuperior corner of the S1 vertebral body.">
				>
				["at0.4"] = <
					text = <"Neutral">
					description = <"The plumb line passes within 2 cm of the posterosuperior corner of the S1 vertebral body.">
				>
				["at0.5"] = <
					text = <"Negative">
					description = <"The plumb line passes more than 2 cm behind the posterosuperior corner of the S1 vertebral body.">
				>
				["at0.6"] = <
					text = <"Spine">
					description = <"">
				>
				["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 entire spine">
					description = <"Findings on radiological examination of the entire spine.">
				>
				["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 = <"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.">
				>
				["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 = <"Sagittal vertikal akse">
					description = <"Den målte lengden av en horisontal linje som forbinder den bakre øvre sakrale endeplaten med en vertikal loddlinje fra C7.">
					comment = <"Omtales også som SVA.
Positive verdier uttrykker at den vertikale loddlinjen ligger anteriort for det posteosuperiore hjørnet av S1. Negative verdier uttrykker at loddlinjen ligger posteriort.">
				>
				["at0.2"] = <
					text = <"C7 loddlinje">
					description = <"Den vertikale linjen trukket fra midten av ryggvirvel C7 i kaudal retning.">
				>
				["at0.3"] = <
					text = <"Positiv">
					description = <"Loddlinjen passerer mer enn 2 cm foran det posterosuperiore hjørnet av S1 virvelen.">
				>
				["at0.4"] = <
					text = <"Nøytral">
					description = <"Loddlinjen passerer innenfor 2 cm fra det posterosuperiore hjørnet av S1 virvelen.">
				>
				["at0.5"] = <
					text = <"Negativ">
					description = <"Loddlinjen passerer mer enn 2 cm bak det posterosuperiore hjørnet av S1 virvelen.">
				>
				["at0.6"] = <
					text = <"Ryggrad">
					description = <"">
				>
				["at0000"] = <
					text = <"Bildediagnostisk undersøkelse - kroppsstruktur">
					description = <"Funn eller observasjoner ved radiologisk undersøkelse av et definert organ eller en kroppsdel.">
				>
				["at0000.1"] = <
					text = <"Bildediagnostisk undersøkelse - hele ryggraden">
					description = <"Funn eller observasjoner ved radiologisk undersøkelse av hele ryggraden.">
				>
				["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 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\".">
				>
				["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 = <"*Imaging examination of the entire spine (en)">
					description = <"*Findings on radiological examination of the entire spine. (en)">
				>
				["at0.1"] = <
					text = <"*Sagittal vertical axis (en)">
					description = <"*The measured length of a horizontal line connecting the posterior superior sacral endplate with a vertical plumb line from C7. (en)">
					comment = <"*Positive values express that the vertical plumb line lies anterior to the posteosuperior corner of S1. Negative values express that the plumb line lies posteriorly. (en)">
				>
				["at0.2"] = <
					text = <"*C7 Plumb Line (en)">
					description = <"*The vertical line drawn from the center of the C7 vertebral body in a caudal direction. (en)">
				>
				["at0.3"] = <
					text = <"*Positive (en)">
					description = <"*The plumb line passes more than 2 cm in front of the posterosuperior corner of the S1 vertebral body (en)">
				>
				["at0.4"] = <
					text = <"*Neutral (en)">
					description = <"*The plumb line passes within 2 cm of the posterosuperior corner of the S1 vertebral body (en)">
				>
				["at0.5"] = <
					text = <"*Negative (en)">
					description = <"*The plumb line passes more than 2 cm behind the posterosuperior corner of the S1 vertebral body (en)">
				>
				["at0001.1"] = <
					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)">
				>
				["at0.6"] = <
					text = <"*Spine (en)">
					description = <"">
				>
				["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 = <
				["at0.6"] = <[SNOMED-CT::44300000]>
			>
		>
	>