ID

29614

Beschreibung

http://openehr.org/ckm/ Use to record examination findings on palpation of the fetus while in utero. This archetype can be used to record either abdominal or vaginal examination findings, including during labor. This archetype has been designed to be nested inside the OBSERVATION.exam archetype or other relevant CLUSTER archetypes, for example providing specific detail about the fetus in CLUSTER.palpation_of_uterus. Record the details of only one fetus using this archetype. Recording details about multiple fetuses will require the multiple separate instances of this archetype.

Link

http://openehr.org/ckm/

Stichworte

Versionen (1)
  1. 10.04.18 10.04.18 - Halim Ugurlu
Rechteinhaber

openEHR Foundation

Hochgeladen am

10. April 2018

DOI

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Lizenz

Creative Commons BY-NC 3.0
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openEHR-EHR-CLUSTER.palpation_of_fetus.v1

Englisch

openEHR-EHR-CLUSTER.palpation_of_fetus.v1

1 Formulare  
  1. StudyEvent: openEHR-EHR-CLUSTER.palpation_of_fetus.v1
    1. openEHR-EHR-CLUSTER.palpation_of_fetus.v1
openEHR-EHR-CLUSTER.palpation_of_fetus.v1.xml
Beschreibung

openEHR-EHR-CLUSTER.palpation_of_fetus.v1.xml

Alias
UMLS CUI-1
C0030247
UMLS CUI-2
C3824618
Palpation of Fetus
Beschreibung

Examination of the fetus by palpation, using either an abdominal or vaginal approach.

Datentyp

text

Alias
UMLS CUI [1,1]
C0030247
UMLS CUI [1,2]
C3824618
UMLS CUI [1,3]
C0175672
UMLS CUI [2]
C0205496
Clinical Description
Beschreibung

Narrative description of findings on examination of the fetus.

Datentyp

text

Alias
UMLS CUI [1,1]
C0678257
UMLS CUI [1,2]
C0205210
Abdominal Findings
Beschreibung

Clinical findings on abdominal palpation.

Datentyp

text

Alias
UMLS CUI [1,1]
C0562238
UMLS CUI [1,2]
C2607943
Lie
Beschreibung

Relationship of the longitudinal axis of the fetus to the long axis of the mother.

Datentyp

text

Abdominal Presentation
Beschreibung

Identification of the part of the fetus lying in the lower part of the uterus.

Datentyp

text

Alias
UMLS CUI [1]
C0022869
Position
Beschreibung

Relationship between the fetal denominator and the maternal pelvis.

Datentyp

text

Alias
UMLS CUI [1]
C0007725
Attitude
Beschreibung

Description of the relationship of the fetal head and limbs to the body of the fetus on palpation.

Datentyp

text

Alias
UMLS CUI [1]
C0231117
Engagement estimation
Beschreibung

The estimated proportion of the presenting part which is felt above the pelvic brim.

Datentyp

text

Alias
UMLS CUI [1,1]
C0426180
UMLS CUI [1,2]
C0680844
Engagement description
Beschreibung

Description of engagement of fetal head.

Datentyp

text

Alias
UMLS CUI [1,1]
C0426180
UMLS CUI [1,2]
C0678257
Relative size
Beschreibung

The relative size of the baby compared to the normal for the estimated gestation.

Datentyp

text

Alias
UMLS CUI [1,1]
C0426043
UMLS CUI [1,2]
C0205345
Estimated weight
Beschreibung

The estimated weight of the fetus on palpation.

Datentyp

float

Alias
UMLS CUI [1,1]
C0005910
UMLS CUI [1,2]
C0750572
Vaginal Findings
Beschreibung

Clinical findings on vaginal palpation.

Datentyp

text

Alias
UMLS CUI [1,1]
C0200048
UMLS CUI [1,2]
C0243095
Vaginal Presentation
Beschreibung

Identification of the presenting part of the fetus.

Datentyp

text

Alias
UMLS CUI [1]
C0022869
Cord presentation?
Beschreibung

Is the umbilical cord presenting?

Datentyp

boolean

Alias
UMLS CUI [1]
C1404746
Station
Beschreibung

Position of the presenting part relative to the ischial spines.

Datentyp

float

Alias
UMLS CUI [1,1]
C0022869
UMLS CUI [1,2]
C1286298
Caput
Beschreibung

Description of caput.

Datentyp

text

Alias
UMLS CUI [1,1]
C0018670
UMLS CUI [1,2]
C0678257
Moulding
Beschreibung

Description of moulding.

Datentyp

text

Alias
UMLS CUI [1]
C0426103
Asynclitism
Beschreibung

Description of asynclitism.

Datentyp

text

Alias
UMLS CUI [1]
C0233304
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Ähnliche Modelle

openEHR-EHR-CLUSTER.palpation_of_fetus.v1

1 Formulare
  1. StudyEvent: openEHR-EHR-CLUSTER.palpation_of_fetus.v1
    1. openEHR-EHR-CLUSTER.palpation_of_fetus.v1
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
openEHR-EHR-CLUSTER.palpation_of_fetus.v1.xml
C0030247 (UMLS CUI-1)
C3824618 (UMLS CUI-2)
Palpation of Fetus
Item
Palpation of Fetus
text
C0030247 (UMLS CUI [1,1])
C3824618 (UMLS CUI [1,2])
C0175672 (UMLS CUI [1,3])
C0205496 (UMLS CUI [2])
Clinical Description
Item
Clinical Description
text
C0678257 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Abdominal Findings
Item
Abdominal Findings
text
C0562238 (UMLS CUI [1,1])
C2607943 (UMLS CUI [1,2])
Item
Lie
text
Lie
Code List
Lie
CL Item
Longitudinal (1)
CL Item
Oblique (2)
CL Item
Transverse (3)
Item
Abdominal Presentation
text
C0022869 (UMLS CUI [1])
Abdominal Presentation
Code List
Abdominal Presentation
CL Item
Vertex (1)
CL Item
Brow (2)
CL Item
Face (3)
CL Item
Breech (4)
CL Item
Shoulder (5)
Item
Position
text
C0007725 (UMLS CUI [1])
Position
Code List
Position
CL Item
Occipito-Anterior (OA) (1)
CL Item
Left Occipito-Anterior (LOA) (2)
CL Item
Left Occipito-Transverse (LOT) (3)
CL Item
Left Occipito-Posterior (LOP) (4)
CL Item
Right Occipito-Anterior (ROA) (5)
CL Item
Right Occipito-Transverse (ROT) (6)
CL Item
Right Occipito-Posterior (ROP) (7)
CL Item
Occipito-Posterior (OP) (8)
CL Item
Sacro-Anterior (SA) (9)
CL Item
Left Sacro-Anterior (LSA) (10)
CL Item
Left Sacro-transverse (LST) (11)
CL Item
Left Sacro-Posterior (LSP) (12)
CL Item
Right Sacro-Anterior (RSA) (13)
CL Item
Right Sacro-Transverse (RST) (14)
CL Item
Right Sacro-Posterior (RSP) (15)
CL Item
Sacro-Posterior (SP) (16)
CL Item
Mento-Anterior (MA) (17)
CL Item
Left Mento-Anterior (LMA) (18)
CL Item
Left Mento-Transverse (LMT) (19)
CL Item
Left Mento-Posterior (LMP) (20)
CL Item
Right Mento-Anterior (RMA) (21)
CL Item
Right Mento-Transverse (RMT) (22)
CL Item
Right Mento-Posterior (RMP) (23)
CL Item
Mento-Posterior (MP) (24)
Item
Attitude
text
C0231117 (UMLS CUI [1])
Attitude
Code List
Attitude
CL Item
Flexed (1)
CL Item
Deflexed (2)
CL Item
Extended (3)
Item
Engagement estimation
text
C0426180 (UMLS CUI [1,1])
C0680844 (UMLS CUI [1,2])
Engagement estimation
Code List
Engagement estimation
CL Item
Not engaged (0/5) (1)
CL Item
1/5 (2)
CL Item
2/5 (3)
CL Item
3/5 (4)
CL Item
4/5 (5)
CL Item
Fully engaged (5/5) (6)
Item
Engagement description
text
C0426180 (UMLS CUI [1,1])
C0678257 (UMLS CUI [1,2])
Engagement description
Code List
Engagement description
CL Item
High and mobile (1)
CL Item
At pelvic brim (2)
CL Item
Engaged (3)
Item
Relative size
text
C0426043 (UMLS CUI [1,1])
C0205345 (UMLS CUI [1,2])
Relative size
Code List
Relative size
CL Item
Small for dates (1)
CL Item
Normal (2)
CL Item
Large for dates (3)
Estimated weight
Item
Estimated weight
float
C0005910 (UMLS CUI [1,1])
C0750572 (UMLS CUI [1,2])
Vaginal Findings
Item
Vaginal Findings
text
C0200048 (UMLS CUI [1,1])
C0243095 (UMLS CUI [1,2])
Item
Vaginal Presentation
text
C0022869 (UMLS CUI [1])
Vaginal Presentation
Code List
Vaginal Presentation
CL Item
Vertex (1)
CL Item
Breech (2)
CL Item
Shoulder (3)
CL Item
Face (4)
CL Item
Brow (5)
CL Item
Foot (6)
CL Item
Arm (7)
Cord presentation?
Item
Cord presentation?
boolean
C1404746 (UMLS CUI [1])
Station
Item
Station
float
C0022869 (UMLS CUI [1,1])
C1286298 (UMLS CUI [1,2])
Caput
Item
Caput
text
C0018670 (UMLS CUI [1,1])
C0678257 (UMLS CUI [1,2])
Moulding
Item
Moulding
text
C0426103 (UMLS CUI [1])
Asynclitism
Item
Asynclitism
text
C0233304 (UMLS CUI [1])
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