Archetype : openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass

Norwegian openEHR Repository

Name

Imaging examination of an adnexal mass

Description

Findings of a morphological abnormality observed in an imaging examination targeting a mass near the uterus, including the ovaries, fallopian tubes, and connecting tissues, using radiographic techniques.

Purpose

To record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting an adnexal mass.

Use

Use to record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting an adnexal mass.

This archetype has been designed to be used in the 'Structured imaging findings' SLOT within the OBSERVATION.imaging_exam_result archetype which will identify the structure containing the morphological abnormality, 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 for a 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.

References

Avgrenet fra: Imaging examination of an adnexal mass, Draft archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2022-06-01]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.5939

Archetype Id

openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0

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. Constraint for DV_CODED_TEXT Morphological abnormality [A morphological abnormality was examined.] Adnexal mass [An adnexal mass was examined.]
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.
Label	0..1	DV_TEXT	A label for the abnormality. Comment Use to differentiate one abnormality from another when there is more than one present at the same site.
Type	0..1	DV_CODED_TEXT	The type of abnormality. Comment Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 \| Mass (morphologic abnormality) \| hierarchy. Constraint for DV_CODED_TEXT Unilocular cyst [A unilocular cyst without septa, solid parts or papillary structures.] Unilocular-solid cyst [A unilocular cyst with a measurable solid component or at least one papillary structure.] Multilocular cyst [A cyst with at least one septum but no measurable solid components or papillary projections.] Multilocular-solid cyst [A cyst with at least one septum and a measurable solid component or at least one papillary projection.] Solid tumour [A tumor where the solid components comprise 80% or more of the tumour when assessed in a two-dimensional section.] Indeterminate [It is not possible to determine the type of mass.]
Diameter	0..3	DV_QUANTITY	A measured diameter of the abnormality. Comment This data element has 3 occurrences to allow for 3 measurements in different axes. DV_QUANTITY
Shape	0..1	DV_TEXT	The shape of the abnormality.
Texture	0..1	DV_TEXT	The texture of the abnormality.
Definition	0..1	CHOICE OF DV_TEXT DV_CODED_TEXT	The definition of the abnormality. Constraint for DV_CODED_TEXT Well-defined [The abnormality is well-defined.] Poorly-defined [The abnormality is poorly-defined.]
Contour	0..1	DV_TEXT	The contour of the abnormality.
Margin	0..1	DV_TEXT	The margin of the abnormality.
Calcification	0..1	DV_CODED_TEXT	Presence of calcification in the abnormality. Constraint for DV_CODED_TEXT Present [Calcification is observed.] Absent [Calcification is not observed.]
Effect	0..1	DV_TEXT	Narrative description about the effect of the abnormality on surrounding structures. Comment For example: 'pressing on blood vessel'.
Vascularisation	0..1	CHOICE OF DV_TEXT DV_CODED_TEXT	Assessment of the blood flow to the abnormality. Comment Often determined by colour doppler or similar. Constraint for DV_CODED_TEXT None [No blood flow can be detected.] Mild [Minimal blood flow can be detected.] Moderate [Moderate blood flow can be detected.] Marked [Marked blood flow can be detected.]
Solid diameter	0..3	DV_QUANTITY	A measured diameter of the largest solid tissue component. Comment This data element has 3 occurrences to allow for 3 measurements in different axes. DV_QUANTITY
Number of cyst locules	0..3	DV_COUNT	The number of cyst locules in the adnexal mass. Constraint for DV_COUNT min: >= 0
Number of papillary projections	0..1	DV_COUNT	The number of papillary projections in the adnexal mass. Constraint for DV_COUNT min: >= 0
Maximal septum width	0..1	DV_QUANTITY	The measured width of the thickest septum. DV_QUANTITY

archetype (adl_version=1.4; uid=0c7dd1ee-ea77-4de6-b037-7aa60d100d9e)
	openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0
specialise
	openEHR-EHR-CLUSTER.imaging_exam-abnormality.v0

concept
	[at0000.1.1]	-- Imaging examination of an adnexal mass
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 = <"Zur Darstellung der Befunde einer radiologischen Untersuchung einer bestimmten Körperstruktur oder -region und deren Interpretation.">
			use = <"*Use to record the findings on radiological examination of a specified body structure or region, and their interpretation.

In practice, the design intent is for the CLUSTER.imaging_exam family of archetypes to be used to record all detailed findings on radiological examination. The family of specialised archetypes are derived from this generic parent archetype, CLUSTER.imaging_exam, designed as a universal pattern for recording any findings in any specified body structure or region and using any modality.

Each structure- or region-specific specialisation of this parent archetype is intended to be inclusive of all reasonably anticipated and relevant findings. For example, the CLUSTER.imaging_exam-ovary will support recording of all findings that would be expected in reporting on imaging of the ovary using any radiological modality, including the size of the ovary, largest follicle size and the diameter and description of specific follicles. Similarly, CLUSTER.imaging_exam-lymph_node_group will contain data elements required to record specific findings of a lymph node group, including its precise or relative location in the body and the number of lymph nodes in the group. 

If an appropriate specialisation is not available for a body structure or region, this archetype can be used to record all relevant findings related to the structure or region. 

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 other relevant CLUSTER.imaging_exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. If this archetype of 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 = <"Nicht zur Darstellung von Befunden verwenden, die außerhalb der identifizierten Körperstruktur oder -region beobachtet wurden. Verwenden Sie zu diesem Zweck eine separate Instanz eines oder mehrerer Archetypen aus der Familie CLUSTER.imaging_exam.

Darf nicht verwendet werden, um Details in Bezug auf die Gesamtbefunde, den Kontext oder technische Details in Bezug auf ein vollständiges Testergebnis einer bildgebenden Untersuchung darzustellen. Verwenden Sie zu diesem Zweck das OBSERVATION.imaging_exam_result. Zum Beispiel Kommentare zur Studienqualität, zu Differenzialdiagnosen und zum Gesamteindruck.">
			copyright = <"© Nasjonal IKT HF">
		>
		["nb"] = <
			language = <[ISO_639-1::nb]>
			purpose = <"For å registrere en fritekstbeskrivelse, strukturerte detaljer og klinisk tolkning av observerte funn eller observasjoner ved bildediagnostisk undersøkelse rettet mot en oppfylning i adneks.">
			use = <"Brukes for å registrere en fritekstbeskrivelse, strukturerte detaljer og klinisk tolkning av observerte funn eller observasjoner ved bildediagnostisk undersøkelse rettet mot en oppfylning i adneks.

Denne arketypen ble utviklet til bruk i SLOT'et \"Strukturerte funn\" i arketypen OBSERVATION.imaging_exam_result (Bildediagnostisk svar) som vil identifisere kroppsstrukturen som inneholder det morfologiske avviket, men kan også brukes innen andre ENTRY- og CLUSTER-arketyper der det er klinisk passende.

Brukes som et rammeverk hvor andre CLUSTER arketyper kan nøstes i SLOT'et \"Strukturerte detaljer\" for å registrere ytterligere strukturerte billedfunn for delstrukturer eller andre relevante funn.">
			misuse = <"Skal ikke brukes til å registrere funn utenfor det spesifiserte organ eller kroppsdel. 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 billedundersøkelsen. Bruk arketypen OBSERVATION.imaging_exam_result (Bildediagnostisk svar) for å registrere for eksempel kommentar om undersøkelseskvalitet, differensialdiagnose og overordnet konklusjon.">
			copyright = <"© Nasjonal IKT HF">
		>
		["en"] = <
			language = <[ISO_639-1::en]>
			purpose = <"To record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting an
 adnexal mass.">
			use = <"Use to record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting an adnexal mass.

This archetype has been designed to be used in the 'Structured imaging findings' SLOT within the OBSERVATION.imaging_exam_result archetype which will identify the structure containing the morphological abnormality, 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 for a 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 = <"© Nasjonal IKT HF">
		>
	>
	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"] = <"Nasjonal IKT">
		["references"] = <"Avgrenet fra: Imaging examination of an adnexal mass, Draft archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2022-06-01]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.5939">
		["original_namespace"] = <"no.nasjonalikt">
		["original_publisher"] = <"Nasjonal IKT">
		["custodian_namespace"] = <"no.nasjonalikt">
		["MD5-CAM-1.0.1"] = <"599667E8E11C2BD3CFBBA672F4CCC08D">
		["build_uid"] = <"28a22a81-6e6b-40d6-8f2a-cf78f72e414d">
		["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[at0000.1.1] matches {    -- Imaging examination of an adnexal mass
		items cardinality matches {1..*; unordered} matches {
			ELEMENT[at0001.1.1] matches {    -- Body structure
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.1,    -- Morphological abnormality
							at0.0.1]    -- Adnexal mass
						}
					}
				}
			}
			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-abnormality(-[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 {    -- Label
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.3.1] occurrences matches {0..1} matches {    -- Type
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.0.2,    -- Unilocular cyst
							at0.0.3,    -- Unilocular-solid cyst
							at0.0.4,    -- Multilocular cyst
							at0.0.5,    -- Multilocular-solid cyst
							at0.0.6,    -- Solid tumour
							at0.0.7]    -- Indeterminate
						}
					}
				}
			}
			ELEMENT[at0.4] occurrences matches {0..3} matches {    -- Diameter
				value matches {
					C_DV_QUANTITY <
						property = <[openehr::122]>
						list = <
							["1"] = <
								units = <"mm">
								magnitude = <|>=0.0|>
								precision = <|0|>
							>
							["2"] = <
								units = <"cm">
								magnitude = <|>=0.0|>
								precision = <|1|>
							>
						>
					>
				}
			}
			ELEMENT[at0.9] occurrences matches {0..1} matches {    -- Shape
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.10] occurrences matches {0..1} matches {    -- Texture
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.11] occurrences matches {0..1} matches {    -- Definition
				value matches {
					DV_TEXT matches {*}
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.12,    -- Well-defined
							at0.13]    -- Poorly-defined
						}
					}
				}
			}
			ELEMENT[at0.14] occurrences matches {0..1} matches {    -- Contour
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.15] occurrences matches {0..1} matches {    -- Margin
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.16] occurrences matches {0..1} matches {    -- Calcification
				value matches {
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.17,    -- Present
							at0.18]    -- Absent
						}
					}
				}
			}
			ELEMENT[at0.19] occurrences matches {0..1} matches {    -- Effect
				value matches {
					DV_TEXT matches {*}
				}
			}
			ELEMENT[at0.20] occurrences matches {0..1} matches {    -- Vascularisation
				value matches {
					DV_TEXT matches {*}
					DV_CODED_TEXT matches {
						defining_code matches {
							[local::
							at0.21,    -- None
							at0.22,    -- Mild
							at0.23,    -- Moderate
							at0.24]    -- Marked
						}
					}
				}
			}
			ELEMENT[at0.0.15] occurrences matches {0..3} matches {    -- Solid diameter
				value matches {
					C_DV_QUANTITY <
						property = <[openehr::122]>
						list = <
							["1"] = <
								units = <"mm">
								magnitude = <|>=0.0|>
								precision = <|0|>
							>
							["2"] = <
								units = <"cm">
								magnitude = <|>=0.0|>
								precision = <|1|>
							>
						>
					>
				}
			}
			ELEMENT[at0.0.8] occurrences matches {0..3} matches {    -- Number of cyst locules
				value matches {
					DV_COUNT matches {
						magnitude matches {|>=0|}
					}
				}
			}
			ELEMENT[at0.0.13] occurrences matches {0..1} matches {    -- Number of papillary projections
				value matches {
					DV_COUNT matches {
						magnitude matches {|>=0|}
					}
				}
			}
			ELEMENT[at0.0.14] occurrences matches {0..1} matches {    -- Maximal septum width
				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 = <
				["at0.0.1"] = <
					text = <"Adnexal mass">
					description = <"An adnexal mass was examined.">
				>
				["at0.0.13"] = <
					text = <"Number of papillary projections">
					description = <"The number of papillary projections in the adnexal mass.">
				>
				["at0.0.14"] = <
					text = <"Maximal septum width">
					description = <"The measured width of the thickest septum.">
				>
				["at0.0.15"] = <
					text = <"Solid diameter">
					description = <"A measured diameter of the largest solid tissue component.">
					comment = <"This data element has 3 occurrences to allow for 3 measurements in different axes.">
				>
				["at0.0.2"] = <
					text = <"Unilocular cyst">
					description = <"A unilocular cyst without septa, solid parts or papillary structures.">
				>
				["at0.0.3"] = <
					text = <"Unilocular-solid cyst">
					description = <"A unilocular cyst with a measurable solid component or at least one papillary structure.">
				>
				["at0.0.4"] = <
					text = <"Multilocular cyst">
					description = <"A cyst with at least one septum but no measurable solid components or papillary projections.">
				>
				["at0.0.5"] = <
					text = <"Multilocular-solid cyst">
					description = <"A cyst with at least one septum and a measurable solid component or at least one papillary projection.">
				>
				["at0.0.6"] = <
					text = <"Solid tumour">
					description = <"A tumor where the solid components comprise 80% or more of the tumour when assessed in a two-dimensional section.">
				>
				["at0.0.7"] = <
					text = <"Indeterminate">
					description = <"It is not possible to determine the type of mass.">
				>
				["at0.0.8"] = <
					text = <"Number of cyst locules">
					description = <"The number of cyst locules in the adnexal mass.">
				>
				["at0.1"] = <
					text = <"Morphological abnormality">
					description = <"A morphological abnormality was examined.">
				>
				["at0.10"] = <
					text = <"Texture">
					description = <"The texture of the abnormality.">
				>
				["at0.11"] = <
					text = <"Definition">
					description = <"The definition of the abnormality.">
				>
				["at0.12"] = <
					text = <"Well-defined">
					description = <"The abnormality is well-defined.">
				>
				["at0.13"] = <
					text = <"Poorly-defined">
					description = <"The abnormality is poorly-defined.">
				>
				["at0.14"] = <
					text = <"Contour">
					description = <"The contour of the abnormality.">
				>
				["at0.15"] = <
					text = <"Margin">
					description = <"The margin of the abnormality.">
				>
				["at0.16"] = <
					text = <"Calcification">
					description = <"Presence of calcification in the abnormality.">
				>
				["at0.17"] = <
					text = <"Present">
					description = <"Calcification is observed.">
				>
				["at0.18"] = <
					text = <"Absent">
					description = <"Calcification is not observed.">
				>
				["at0.19"] = <
					text = <"Effect">
					description = <"Narrative description about the effect of the abnormality on surrounding structures.">
					comment = <"For example: 'pressing on blood vessel'.">
				>
				["at0.2"] = <
					text = <"Label">
					description = <"A label for the abnormality.">
					comment = <"Use to differentiate one abnormality from another when there is more than one present at the same site.">
				>
				["at0.20"] = <
					text = <"Vascularisation">
					description = <"Assessment of the blood flow to the abnormality.">
					comment = <"Often determined by colour doppler or similar.">
				>
				["at0.21"] = <
					text = <"None">
					description = <"No blood flow can be detected.">
				>
				["at0.22"] = <
					text = <"Mild">
					description = <"Minimal blood flow can be detected.">
				>
				["at0.23"] = <
					text = <"Moderate">
					description = <"Moderate blood flow can be detected.">
				>
				["at0.24"] = <
					text = <"Marked">
					description = <"Marked blood flow can be detected.">
				>
				["at0.3"] = <
					text = <"Type">
					description = <"The type of abnormality.">
					comment = <"Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy.">
				>
				["at0.3.1"] = <
					text = <"Type">
					description = <"The type of abnormality.">
					comment = <"Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy.">
				>
				["at0.4"] = <
					text = <"Diameter">
					description = <"A measured diameter of the abnormality.">
					comment = <"This data element has 3 occurrences to allow for 3 measurements in different axes.">
				>
				["at0.5"] = <
					text = <"Diameter">
					description = <"A measured diameter of the abnormality.">
				>
				["at0.6"] = <
					text = <"Dimension 1">
					description = <"The measured length of the longest axis of the abnormality.">
				>
				["at0.7"] = <
					text = <"Dimension 2">
					description = <"The measured length of an axis of the abnormality perpendicular to Dimension 1.">
				>
				["at0.8"] = <
					text = <"Dimension 3">
					description = <"The measured length of an axis of the abnormality perpendicular to Dimension 1 and Dimension 2..">
				>
				["at0.9"] = <
					text = <"Shape">
					description = <"The shape of the abnormality.">
				>
				["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 an abnormality">
					description = <"Findings of a morphological abnormality observed in an imaging examination targeting a specified structure or region, using radiographic techniques.">
				>
				["at0000.1.1"] = <
					text = <"Imaging examination of an adnexal mass">
					description = <"Findings of a morphological abnormality observed in an imaging examination targeting a mass near the uterus, including the ovaries, fallopian tubes, and connecting tissues, using radiographic techniques.">
				>
				["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.">
				>
				["at0001.1"] = <
					text = <"Body structure">
					description = <"Identification of the body structure or region examined.">
				>
				["at0001.1.1"] = <
					text = <"Body structure">
					description = <"Identification of the body structure or region examined.">
				>
				["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 = <
				["at0.0.1"] = <
					text = <"Oppfylning i adneks">
					description = <"Undersøkelse av en oppfylning i adneks.">
				>
				["at0.0.13"] = <
					text = <"Antall papillære utspring">
					description = <"Antall papillære utspring i oppfylningen.">
				>
				["at0.0.14"] = <
					text = <"Største bredde av skilleveggen">
					description = <"Den største bredden av skilleveggen.">
				>
				["at0.0.15"] = <
					text = <"Solid diameter">
					description = <"Diameter for den største solide vevskomponenten.">
					comment = <"Elementet har 3 forekomster for å tillate registrering av målinger i 3 retninger.">
				>
				["at0.0.2"] = <
					text = <"Enkamret cyste">
					description = <"Enkamret cyste uten skillevegg, solide deler eller papillære strukturer.">
				>
				["at0.0.3"] = <
					text = <"Enkamret-solid cyste">
					description = <"En enkamret cyste med målbar solid komponent eller minst en papiller struktur.">
				>
				["at0.0.4"] = <
					text = <"Flerkamret cyste">
					description = <"En cyste med minst en skillevegg, men ingen målbare solide komponenter eller papillære utspring.">
				>
				["at0.0.5"] = <
					text = <"Flerkamret-solid cyste">
					description = <"En cyste med minst en skillevegg og målbar solid komponent eller minst ett papillært utspring.">
				>
				["at0.0.6"] = <
					text = <"Solid svulst">
					description = <"En svulst hvor den solide komponenten utgjør 80% eller mer av svulsten, sett på i et todimensjonalt snitt.">
				>
				["at0.0.7"] = <
					text = <"Ubestemmelig">
					description = <"Det er umulig å bestemme oppfyllingens type.">
				>
				["at0.0.8"] = <
					text = <"Antall cystiske kamre">
					description = <"Antall cystiske kamre i oppfylningen.">
				>
				["at0.1"] = <
					text = <"Morfologisk avvik">
					description = <"Undersøkelse av et morfologisk avvik.">
				>
				["at0.10"] = <
					text = <"Tekstur">
					description = <"Avvikets tekstur.">
				>
				["at0.11"] = <
					text = <"Avgrensning">
					description = <"Avvikets avgrensning.">
				>
				["at0.12"] = <
					text = <"Godt avgrenset">
					description = <"Avviket er godt avgrenset.">
				>
				["at0.13"] = <
					text = <"Svakt avgrenset">
					description = <"Avviket er svakt avgrenset.">
				>
				["at0.14"] = <
					text = <"Kontur">
					description = <"Avvikets kontur.">
				>
				["at0.15"] = <
					text = <"Grenseflate">
					description = <"Avvikets grenseflate.">
				>
				["at0.16"] = <
					text = <"Forkalkning">
					description = <"Tilstedeværelse av forkalkning i avviket.">
				>
				["at0.17"] = <
					text = <"Tilstede">
					description = <"Forkalkning kan sees.">
				>
				["at0.18"] = <
					text = <"Fraværende">
					description = <"Forkalkning kan ikke sees.">
				>
				["at0.19"] = <
					text = <"Effekt">
					description = <"Fritekstbeskrivelse av avvikets effekt på omkringliggende strukturer.">
					comment = <"Eksempelvis 'presser mot blodkar'.">
				>
				["at0.2"] = <
					text = <"Identifisering">
					description = <"Identifisering eller betegnelse for avviket.">
					comment = <"Brukes for a skille mellom et avvik fra et annet når flere avvik er tilstede samtidig.">
				>
				["at0.20"] = <
					text = <"Blodforsyning">
					description = <"Undersøkelse av avvikets blodforsyning.">
					comment = <"Undersøkes ofte med fargedoppler eller lignende metode.">
				>
				["at0.21"] = <
					text = <"Ingen">
					description = <"Ingen blodforsyning kan sees.">
				>
				["at0.22"] = <
					text = <"Mild">
					description = <"Liten blodtilstrømning kan sees.">
				>
				["at0.23"] = <
					text = <"Moderat">
					description = <"Moderat blodtilstrømning kan sees.">
				>
				["at0.24"] = <
					text = <"Markert">
					description = <"Markert blodtilstrømning kan sees.">
				>
				["at0.3"] = <
					text = <"Type">
					description = <"Avvikets type.">
					comment = <"Det bør om mulig benyttes ekstern terminologi for å angi den morfologisk typen for avvik. Eksempelvis cyste eller knute fra SNOMED 4147007 | Oppfylning (morfologisk avvik) | hierarki.">
				>
				["at0.3.1"] = <
					text = <"Type">
					description = <"Type for avviket.">
					comment = <"Det bør om mulig benyttes ekstern terminologi for å angi den morfologisk typen for avvik. Eksempelvis cyste eller knute fra SNOMED 4147007 | Oppfylning (morfologisk avvik) | hierarki.">
				>
				["at0.4"] = <
					text = <"Diameter">
					description = <"Avvikets diameter.">
					comment = <"Elementet har 3 forekomster for å tillate registrering av målinger i 3 retninger.">
				>
				["at0.5"] = <
					text = <"*Diameter(en)">
					description = <"*A measured diameter of the abnormality.(en)">
				>
				["at0.6"] = <
					text = <"*Dimension 1(en)">
					description = <"*The measured length of the longest axis of the abnormality.(en)">
				>
				["at0.7"] = <
					text = <"*Dimension 2(en)">
					description = <"*The measured length of an axis of the abnormality perpendicular to Dimension 1.(en)">
				>
				["at0.8"] = <
					text = <"*Dimension 3(en)">
					description = <"*The measured length of an axis of the abnormality perpendicular to Dimension 1 and Dimension 2..(en)">
				>
				["at0.9"] = <
					text = <"Form">
					description = <"Avvikets form.">
				>
				["at0000"] = <
					text = <"Bildediagnostisk undersøkelse - kroppsstruktur">
					description = <"Funn eller observasjoner ved radiologisk undersøkelse av et definert organ eller en kroppsdel.">
				>
				["at0000.1"] = <
					text = <"Bildeundersøkelse av et avvik">
					description = <"Funn ved bildeundersøkelse av et morfologisk avvik med bruk av radiologiske metoder rettet mot en spesifisert struktur eller område.">
				>
				["at0000.1.1"] = <
					text = <"Bildediagnostisk undersøkelse - oppfylning i adneks">
					description = <"Funn eller observasjoner ved bildeundersøkelse av en oppfylning i livmorens adneks, herunder eggstokk, eggledere og omkringliggende vev, 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.">
				>
				["at0001.1"] = <
					text = <"Struktur">
					description = <"Navn av undersøkt struktur eller område på eller i kroppen.">
				>
				["at0001.1.1"] = <
					text = <"Struktur">
					description = <"Navn av undersøkt struktur eller område på eller i kroppen.">
				>
				["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 = <
				["at0.0.1"] = <
					text = <"Adnexal mass">
					description = <"An adnexal mass was examined.">
				>
				["at0.0.13"] = <
					text = <"Number of papillary projections">
					description = <"The number of papillary projections in the adnexal mass.">
				>
				["at0.0.14"] = <
					text = <"Maximal septum width">
					description = <"The measured width of the thickest septum.">
				>
				["at0.0.15"] = <
					text = <"Solid diameter">
					description = <"A measured diameter of the largest solid tissue component.">
					comment = <"This data element has 3 occurrences to allow for 3 measurements in different axes.">
				>
				["at0.0.2"] = <
					text = <"Unilocular cyst">
					description = <"A unilocular cyst without septa, solid parts or papillary structures.">
				>
				["at0.0.3"] = <
					text = <"Unilocular-solid cyst">
					description = <"A unilocular cyst with a measurable solid component or at least one papillary structure.">
				>
				["at0.0.4"] = <
					text = <"Multilocular cyst">
					description = <"A cyst with at least one septum but no measurable solid components or papillary projections.">
				>
				["at0.0.5"] = <
					text = <"Multilocular-solid cyst">
					description = <"A cyst with at least one septum and a measurable solid component or at least one papillary projection.">
				>
				["at0.0.6"] = <
					text = <"Solid tumour">
					description = <"A tumor where the solid components comprise 80% or more of the tumour when assessed in a two-dimensional section.">
				>
				["at0.0.7"] = <
					text = <"Indeterminate">
					description = <"It is not possible to determine the type of mass.">
				>
				["at0.0.8"] = <
					text = <"Number of cyst locules">
					description = <"The number of cyst locules in the adnexal mass.">
				>
				["at0.3.1"] = <
					text = <"Type">
					description = <"The type of abnormality.">
					comment = <"Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy.">
				>
				["at0.5"] = <
					text = <"Diameter">
					description = <"A measured diameter of the abnormality.">
				>
				["at0.6"] = <
					text = <"Dimension 1">
					description = <"The measured length of the longest axis of the abnormality.">
				>
				["at0.7"] = <
					text = <"Dimension 2">
					description = <"The measured length of an axis of the abnormality perpendicular to Dimension 1.">
				>
				["at0.8"] = <
					text = <"Dimension 3">
					description = <"The measured length of an axis of the abnormality perpendicular to Dimension 1 and Dimension 2..">
				>
				["at0000.1.1"] = <
					text = <"Bildgebende Untersuchung einer Körperstruktur">
					description = <"Befunde zur radiologischen Untersuchung einer bestimmten Körperstruktur oder -region.">
				>
				["at0001.1.1"] = <
					text = <"Körperstruktur">
					description = <"Identifizierung der untersuchten Körperstruktur oder Region.">
					comment = <"Zum Beispiel: „Leber“, „Rechtes Fußgelenk“ oder „Lymphknotengruppe“. Es wird empfohlen, die Körperstruktur mit einer geeigneten Terminologie, wie z. B. SNOMED CT, zu codieren.">
				>
				["at0005"] = <
					text = <"Zusätzliche Angaben">
					description = <"Zusätzliche strukturierte Angaben zu bildgebenden Befunden für die identifizierte Körperstruktur oder -region oder befundbezogene Strukturen.">
				>
				["at0000"] = <
					text = <"Bildgebende Untersuchung einer Körperstruktur">
					description = <"Befunde zur radiologischen Untersuchung einer bestimmten Körperstruktur oder -region.">
				>
				["at0007"] = <
					text = <"Kommentar">
					description = <"Zusätzlicher Text über die bildgebenden Befunde der Körperstruktur, der in anderen Bereichen nicht erfasst wurde.">
				>
				["at0001"] = <
					text = <"Körperstruktur">
					description = <"Identifizierung der untersuchten Körperstruktur oder Region.">
					comment = <"Zum Beispiel: „Leber“, „Rechtes Fußgelenk“ oder „Lymphknotengruppe“. Es wird empfohlen, die Körperstruktur mit einer geeigneten Terminologie, wie z. B. SNOMED CT, zu codieren.">
				>
				["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.">
				>
				["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.">
				>
				["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.">
				>
				["at0.1"] = <
					text = <"Morphological abnormality">
					description = <"A morphological abnormality was examined.">
				>
				["at0.10"] = <
					text = <"Texture">
					description = <"The texture of the abnormality.">
				>
				["at0.11"] = <
					text = <"Definition">
					description = <"The definition of the abnormality.">
				>
				["at0.12"] = <
					text = <"Well-defined">
					description = <"The abnormality is well-defined.">
				>
				["at0.13"] = <
					text = <"Poorly-defined">
					description = <"The abnormality is poorly-defined.">
				>
				["at0.14"] = <
					text = <"Contour">
					description = <"The contour of the abnormality.">
				>
				["at0.15"] = <
					text = <"Margin">
					description = <"The margin of the abnormality.">
				>
				["at0.16"] = <
					text = <"Calcification">
					description = <"Presence of calcification in the abnormality.">
				>
				["at0.17"] = <
					text = <"Present">
					description = <"Calcification is observed.">
				>
				["at0.18"] = <
					text = <"Absent">
					description = <"Calcification is not observed.">
				>
				["at0.19"] = <
					text = <"Effect">
					description = <"Narrative description about the effect of the abnormality on surrounding structures.">
					comment = <"For example: 'pressing on blood vessel'.">
				>
				["at0.2"] = <
					text = <"Label">
					description = <"A label for the abnormality.">
					comment = <"Use to differentiate one abnormality from another when there is more than one present at the same site.">
				>
				["at0.20"] = <
					text = <"Vascularisation">
					description = <"Assessment of the blood flow to the abnormality.">
					comment = <"Often determined by colour doppler or similar.">
				>
				["at0.21"] = <
					text = <"None">
					description = <"No blood flow can be detected.">
				>
				["at0.22"] = <
					text = <"Mild">
					description = <"Minimal blood flow can be detected.">
				>
				["at0.23"] = <
					text = <"Moderate">
					description = <"Moderate blood flow can be detected.">
				>
				["at0.24"] = <
					text = <"Marked">
					description = <"Marked blood flow can be detected.">
				>
				["at0.3"] = <
					text = <"Type">
					description = <"The type of abnormality.">
					comment = <"Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy.">
				>
				["at0.4"] = <
					text = <"Diameter">
					description = <"A measured diameter of the abnormality.">
					comment = <"This data element has 3 occurrences to allow for 3 measurements in different axes.">
				>
				["at0.9"] = <
					text = <"Shape">
					description = <"The shape of the abnormality.">
				>
				["at0000.1"] = <
					text = <"Bildgebende Untersuchung einer Körperstruktur">
					description = <"Befunde zur radiologischen Untersuchung einer bestimmten Körperstruktur oder -region.">
				>
				["at0001.1"] = <
					text = <"Körperstruktur">
					description = <"Identifizierung der untersuchten Körperstruktur oder Region.">
					comment = <"Zum Beispiel: „Leber“, „Rechtes Fußgelenk“ oder „Lymphknotengruppe“. Es wird empfohlen, die Körperstruktur mit einer geeigneten Terminologie, wie z. B. SNOMED CT, zu codieren.">
				>
				["at0004"] = <
					text = <"Bildgebende Befunde">
					description = <"Beschreibung der bei dieser Untersuchung beobachteten bildgebenden Befunde.">
				>
			>
		>
	>
	term_bindings = <
		["SNOMED-CT"] = <
			items = <
				["at0.0.1"] = <[SNOMED-CT::445039006]>
				["at0.1"] = <[SNOMED-CT::49755003]>
			>
		>
	>