OpenEHR Master CKM Mirror
Name
Imaging examination of a pregnant uterus
Description
Findings on radiological examination of a pregnant uterus.
Purpose
To record the findings on radiological examination of a pregnant uterus, and their interpretation.
Use
Use to record the findings on radiological examination of a pregnant uterus, and their interpretation.
The intended scope for this archetype is to eventually record all detailed findings on radiological examination of a pregnant uterus 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 'Additional details' SLOT in the CLUSTER.imaging_exam-uterus 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.
The intended scope for this archetype is to eventually record all detailed findings on radiological examination of a pregnant uterus 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 'Additional details' SLOT in the CLUSTER.imaging_exam-uterus 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 non pregnancy-related imaging examination findings for the uterus. Use other archetypes from the CLUSTER.imaging_exam-uterus for this purpose.
Not to be used to record imaging examination findings for any body structure or region other than a pregnant uterus. Use other archetypes from the CLUSTER.imaging_exam family for this purpose.
Not to be used to record the estimated gestational age. Use OBSERVATION.gestation 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.
Not to be used to record imaging examination findings for any body structure or region other than a pregnant uterus. Use other archetypes from the CLUSTER.imaging_exam family for this purpose.
Not to be used to record the estimated gestational age. Use OBSERVATION.gestation 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.
Archetype Id
openEHR-EHR-CLUSTER.imaging_exam-pregnant_uterus.v0
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
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
|
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.
|
Gestational sac presence
|
0..1 | DV_CODED_TEXT |
Presence of a gestational sac within the uterus.
Constraint for DV_CODED_TEXT
|
Number of gestational sacs
|
0..1 | DV_COUNT |
Number of gestational sacs observed in the uterus.
|
Gestational sac findings
|
0..1 | Slot (Cluster) |
Structured details about a single observed gestational sac within the uterus.
Slot
Slot
|
Number of foetuses
|
0..1 | DV_COUNT |
Number of fetuses observed in the uterus.
|
Amnionicity
|
0..1 |
CHOICE OF
DV_COUNT
DV_CODED_TEXT
|
The number of amnions (inner membranes) that surround the embryos or fetuses in a multiple pregnancy.
Constraint for DV_CODED_TEXT
|
Chorionicity
|
0..1 |
CHOICE OF
DV_COUNT
DV_CODED_TEXT
|
The number of placental masses observed in a multiple pregnancy.
Constraint for DV_CODED_TEXT
|
Placental findings
|
0..* | Slot (Cluster) |
Structured details about a single placenta/placental mass.
Slot
Slot
|
Foetal findings
|
0..* | Slot (Cluster) |
Structured details about a single foetus.
Slot
Slot
|
archetype (adl_version=1.4; uid=0ea59022-c082-4a63-8866-a05c2036f773) openEHR-EHR-CLUSTER.imaging_exam-pregnant_uterus.v0 specialise openEHR-EHR-CLUSTER.imaging_exam.v1 concept [at0000.1] -- Imaging examination of a pregnant uterus 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 a pregnant uterus, and their interpretation. (en)"> use = <"*Use to record the findings on radiological examination of a pregnant uterus, and their interpretation. The intended scope for this archetype is to eventually record all detailed findings on radiological examination of a pregnant uterus 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 'Additional details' SLOT in the CLUSTER.imaging_exam-uterus 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. (en)"> keywords = <"Befund, Ergebnis, Bildgebung, Körper, Organ, System, Struktur, Region, Beobachtung, Diagnostik, Radiologie, Bild", ...> misuse = <"*Not to be used to record non pregnancy-related imaging examination findings for the uterus. Use other archetypes from the CLUSTER.imaging_exam-uterus for this purpose. Not to be used to record imaging examination findings for any body structure or region other than a pregnant uterus. Use other archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record the estimated gestational age. Use OBSERVATION.gestation 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 = <"*To record the findings on radiological examination of a pregnant uterus, and their interpretation. (en)"> use = <"*Use to record the findings on radiological examination of a pregnant uterus, and their interpretation. The intended scope for this archetype is to eventually record all detailed findings on radiological examination of a pregnant uterus 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 'Additional details' SLOT in the CLUSTER.imaging_exam-uterus 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. (en)"> misuse = <"*Not to be used to record non pregnancy-related imaging examination findings for the uterus. Use other archetypes from the CLUSTER.imaging_exam-uterus for this purpose. Not to be used to record imaging examination findings for any body structure or region other than a pregnant uterus. Use other archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record the estimated gestational age. Use OBSERVATION.gestation 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)"> > ["en"] = < language = <[ISO_639-1::en]> purpose = <"To record the findings on radiological examination of a pregnant uterus, and their interpretation."> use = <"Use to record the findings on radiological examination of a pregnant uterus, and their interpretation. The intended scope for this archetype is to eventually record all detailed findings on radiological examination of a pregnant uterus 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 'Additional details' SLOT in the CLUSTER.imaging_exam-uterus 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 non pregnancy-related imaging examination findings for the uterus. Use other archetypes from the CLUSTER.imaging_exam-uterus for this purpose. Not to be used to record imaging examination findings for any body structure or region other than a pregnant uterus. Use other archetypes from the CLUSTER.imaging_exam family for this purpose. Not to be used to record the estimated gestational age. Use OBSERVATION.gestation 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 = <"in_development"> 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", "Anne Helbig, MD PhD, Oslo University Hospital, Norway", "Anca Heyd, DIPS ASA, Norway", "Evelyn Hovenga, EJSH Consulting, Australia", "Mikkel Johan Gaup Grønmo, Regional forvaltning EPJ, Helse Nord, Norway (Nasjonal IKT redaktør)", "Anjali Kulkarni, Karkinos, India", "Liv Laugen, Oslo University Hospital, Norway, Norway (openEHR Editor)", "Heather Leslie, Atomica Informatics, Australia (openEHR Editor)", "Mikael Nyström, Cambio Healthcare Systems AB, Sweden", "Norwegian Review Summary, Norwegian Public Hospitals, Norway", "Tina Tellum, Oslo Universitetssykehus, Norway", "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"> ["original_namespace"] = <"org.openehr"> ["original_publisher"] = <"openEHR Foundation"> ["custodian_namespace"] = <"org.openehr"> ["MD5-CAM-1.0.1"] = <"533FFE9077144E44F0A15BCE4296DC2A"> ["build_uid"] = <"7a0f5eb9-27b1-410b-9247-78835669a129"> ["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 a pregnant uterus items cardinality matches {1..*; unordered} matches { ELEMENT[at0001.1] matches { -- Body structure value matches { DV_CODED_TEXT matches { defining_code matches { [local::at0.1] -- Pregnant uterus } } } } 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-adnexal_mass(-[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 { -- Gestational sac presence value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.3, -- Present at0.4, -- Absent at0.5] -- Indeterminate } } } } ELEMENT[at0.7] occurrences matches {0..1} matches { -- Number of gestational sacs value matches { DV_COUNT matches {*} } } allow_archetype CLUSTER[at0.6] occurrences matches {0..1} matches { -- Gestational sac findings include archetype_id/value matches {/openEHR-EHR-CLUSTER\.imaging_exam-gestational_sac(-[a-zA-Z0-9_]+)*\.v0/} } ELEMENT[at0.8] occurrences matches {0..1} matches { -- Number of foetuses value matches { DV_COUNT matches {*} } } ELEMENT[at0.9] occurrences matches {0..1} matches { -- Amnionicity value matches { DV_COUNT matches {*} DV_CODED_TEXT matches { defining_code matches { [local:: at0.14, -- Monoamnionic at0.15] -- Diamnionic } } } } ELEMENT[at0.10] occurrences matches {0..1} matches { -- Chorionicity value matches { DV_COUNT matches {*} DV_CODED_TEXT matches { defining_code matches { [local:: at0.16, -- Monochorionic at0.17] -- Dichorionic } } } } allow_archetype CLUSTER[at0.11] occurrences matches {0..*} matches { -- Placental findings include archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0.12] occurrences matches {0..*} matches { -- Foetal findings include archetype_id/value matches {/openEHR-EHR-CLUSTER\.imaging_exam-foetus\.v0/} } } } ontology term_definitions = < ["en"] = < items = < ["at0000.1"] = < text = <"Imaging examination of a pregnant uterus"> description = <"Findings on radiological examination of a pregnant uterus."> > ["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."> > ["at0.1"] = < text = <"Pregnant uterus"> description = <""> > ["at0.2"] = < text = <"Gestational sac presence"> description = <"Presence of a gestational sac within the uterus."> > ["at0.3"] = < text = <"Present"> description = <"A gestational sac is observed."> > ["at0.4"] = < text = <"Absent"> description = <"No gestational sac is observed."> > ["at0.5"] = < text = <"Indeterminate"> description = <"It is not possible to determine if a gestational sac is present or absent."> > ["at0.6"] = < text = <"Gestational sac findings"> description = <"Structured details about a single observed gestational sac within the uterus."> > ["at0.7"] = < text = <"Number of gestational sacs"> description = <"Number of gestational sacs observed in the uterus."> > ["at0.8"] = < text = <"Number of foetuses"> description = <"Number of fetuses observed in the uterus."> > ["at0.9"] = < text = <"Amnionicity"> description = <"The number of amnions (inner membranes) that surround the embryos or fetuses in a multiple pregnancy."> > ["at0.10"] = < text = <"Chorionicity"> description = <"The number of placental masses observed in a multiple pregnancy."> > ["at0.11"] = < text = <"Placental findings"> description = <"Structured details about a single placenta/placental mass."> > ["at0.12"] = < text = <"Foetal findings"> description = <"Structured details about a single foetus."> > ["at0.14"] = < text = <"Monoamnionic"> description = <"One amniotic sac is observed."> > ["at0.15"] = < text = <"Diamnionic"> description = <"Two amniotic sacs are observed."> > ["at0.16"] = < text = <"Monochorionic"> description = <"One chorion or placenta is observed."> > ["at0.17"] = < text = <"Dichorionic"> description = <"Two chorions or placentas are observed."> > ["at0000"] = < text = <"Imaging examination of a body structure"> description = <"Findings on radiological examination of a specified body structure or region."> > ["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."> > ["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 = <"*Pregnant uterus (en)"> description = <""> > ["at0000.1"] = < text = <"*Imaging examination of a pregnant uterus (en)"> description = <"*Findings on radiological examination of a pregnant uterus. (en)"> > ["at0001.1"] = < text = <"Struktur"> description = <"Navn av undersøkt struktur eller område på eller i kroppen."> 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)"> > ["at0.2"] = < text = <"*Gestational sac presence (en)"> description = <"*Presence of a gestational sac within the uterus. (en)"> > ["at0.3"] = < text = <"*Present (en)"> description = <"*A gestational sac is observed. (en)"> > ["at0.4"] = < text = <"*Absent (en)"> description = <"*No gestational sac is observed. (en)"> > ["at0.5"] = < text = <"*Indeterminate (en)"> description = <"*It is not possible to determine if a gestational sac is present or absent. (en)"> > ["at0.6"] = < text = <"*Gestational sac findings (en)"> description = <"*Structured details about a single observed gestational sac within the uterus. (en)"> > ["at0.7"] = < text = <"*Number of gestational sacs (en)"> description = <"*Number of gestational sacs observed in the uterus. (en)"> > ["at0.8"] = < text = <"*Number of foetuses (en)"> description = <"*Number of fetuses observed in the uterus. (en)"> > ["at0.9"] = < text = <"*Amnionicity (en)"> description = <"*The number of amnions (inner membranes) that surround the embryos or fetuses in a multiple pregnancy. (en)"> > ["at0.10"] = < text = <"*Chorionicity (en)"> description = <"*The number of placental masses observed in a multiple pregnancy. (en)"> > ["at0.11"] = < text = <"*Placental findings (en)"> description = <"*Structured details about a single placenta/placental mass. (en)"> > ["at0.12"] = < text = <"*Foetal findings (en)"> description = <"*Structured details about a single foetus. (en)"> > ["at0.14"] = < text = <"*Monoamnionic (en)"> description = <"*One amniotic sac is observed. (en)"> > ["at0.15"] = < text = <"*Diamnionic (en)"> description = <"*Two amniotic sacs are observed. (en)"> > ["at0.16"] = < text = <"*Monochorionic (en)"> description = <"*One chorion or placenta is observed. (en)"> > ["at0.17"] = < text = <"*Dichorionic (en)"> description = <"*Two chorions or placentas are observed. (en)"> > ["at0000"] = < text = <"Bildediagnostisk undersøkelse - kroppsstruktur"> description = <"Funn eller observasjoner ved radiologisk undersøkelse av et definert organ eller en kroppsdel."> > ["at0001"] = < text = <"Kroppsstruktur"> description = <"Identifisering av organet eller kroppsdelen som svaret gjelder."> 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 = <"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 a pregnant uterus (en)"> description = <"*Findings on radiological examination of a pregnant uterus. (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 = <"*Pregnant uterus (en)"> description = <""> > ["at0.2"] = < text = <"*Gestational sac presence (en)"> description = <"*Presence of a gestational sac within the uterus. (en)"> > ["at0.3"] = < text = <"*Present (en)"> description = <"*A gestational sac is observed. (en)"> > ["at0.4"] = < text = <"*Absent (en)"> description = <"*No gestational sac is observed. (en)"> > ["at0.5"] = < text = <"*Indeterminate (en)"> description = <"*It is not possible to determine if a gestational sac is present or absent. (en)"> > ["at0.6"] = < text = <"*Gestational sac findings (en)"> description = <"*Structured details about a single observed gestational sac within the uterus. (en)"> > ["at0.7"] = < text = <"*Number of gestational sacs (en)"> description = <"*Number of gestational sacs observed in the uterus. (en)"> > ["at0.8"] = < text = <"*Number of foetuses (en)"> description = <"*Number of fetuses observed in the uterus. (en)"> > ["at0.9"] = < text = <"*Amnionicity (en)"> description = <"*The number of amnions (inner membranes) that surround the embryos or fetuses in a multiple pregnancy. (en)"> > ["at0.10"] = < text = <"*Chorionicity (en)"> description = <"*The number of placental masses observed in a multiple pregnancy. (en)"> > ["at0.11"] = < text = <"*Placental findings (en)"> description = <"*Structured details about a single placenta/placental mass. (en)"> > ["at0.12"] = < text = <"*Foetal findings (en)"> description = <"*Structured details about a single foetus. (en)"> > ["at0.14"] = < text = <"*Monoamnionic (en)"> description = <"*One amniotic sac is observed. (en)"> > ["at0.15"] = < text = <"*Diamnionic (en)"> description = <"*Two amniotic sacs are observed. (en)"> > ["at0.16"] = < text = <"*Monochorionic (en)"> description = <"*One chorion or placenta is observed. (en)"> > ["at0.17"] = < text = <"*Dichorionic (en)"> description = <"*Two chorions or placentas are observed. (en)"> > ["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."> > > > >