ID

29615

Description

http://openehr.org/ckm/ Use to record examination findings on palpation of the uterus. This archetype can be used to record either abdominal or vaginal examination findings, and including findings about the pregnant uterus. This archetype has been designed to be nested inside the OBSERVATION.exam archetype (and its specialisations) or other relevant CLUSTER archetypes, for example providing specific detail in CLUSTER.palpation_of_abdomen which describes palpation of the whole abdomen.

Link

http://openehr.org/ckm/

Keywords

Versions (1)
  1. 4/10/18 4/10/18 - Halim Ugurlu
Copyright Holder

openEHR Foundation

Uploaded on

April 10, 2018

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

openEHR-EHR-CLUSTER.palpation_of_uterus.v1

English

openEHR-EHR-CLUSTER.palpation_of_uterus.v1

1 forms  
  1. StudyEvent: openEHR-EHR-CLUSTER.palpation_of_uterus.v1
    1. openEHR-EHR-CLUSTER.palpation_of_uterus.v1
openEHR-EHR-CLUSTER.palpation_of_uterus.v1.xml
Description

openEHR-EHR-CLUSTER.palpation_of_uterus.v1.xml

Alias
UMLS CUI-1
C0042149
UMLS CUI-2
C0030247
Palpation of Uterus
Description

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

Data type

text

Alias
UMLS CUI [1,1]
C0042149
UMLS CUI [1,2]
C0030247
Clinical Description
Description

Narrative description of findings on examination of the uterus.

Data type

text

Alias
UMLS CUI [1,1]
C0678257
UMLS CUI [1,2]
C0205210
Position
Description

Position of uterus.

Data type

text

Alias
UMLS CUI [1]
C0425916
Fundal Height
Description

The height of the uterine fundus measured from the symphysis pubis.

Data type

float

Alias
UMLS CUI [1,1]
C0733755
UMLS CUI [1,2]
C0227817
Gestation
Description

Uterine size estimation, expressed as length of gestation.

Data type

text

Alias
UMLS CUI [1]
C1135241
Uterine size
Description

Measurement or estimation of the size of the uterus.

Data type

text

Alias
UMLS CUI [1,1]
C0042149
UMLS CUI [1,2]
C0456389
Relative Size
Description

Estimated size of the uterus relative to commonly used anatomical markers, estimations of pregnancy gestation (even if non-pregnant) or common objects.

Data type

text

Alias
UMLS CUI [1,1]
C0042149
UMLS CUI [1,2]
C0456389
UMLS CUI [1,3]
C0750572
Liquor Volume
Description

Assessment of the relative amount of liquor present in the uterus.

Data type

text

Alias
UMLS CUI [1]
C0002638
Number of Fetuses
Description

The number of fetuses found on palpation of the uterus.

Data type

integer

Alias
UMLS CUI [1]
C0422809
Fetal Detail
Description

Detailed information about the fetus. Record details about each fetus in a multiple birth separately.

Data type

text

Alias
UMLS CUI [1,1]
C0521457
UMLS CUI [1,2]
C1522508
Surface
Description

Narrative description of the surface and shape of the uterus.

Data type

text

Alias
UMLS CUI [1,1]
C0205148
UMLS CUI [1,2]
C0332479
UMLS CUI [1,3]
C0042149
Consistency
Description

Narrative description of the consistency of the uterus.

Data type

text

Alias
UMLS CUI [1,1]
C0332529
UMLS CUI [1,2]
C0042149
Tenderness
Description

Narrative description of any findings of tenderness.

Data type

text

Alias
UMLS CUI [1]
C0567083
Mobility
Description

Mobility of the uterus.

Data type

text

Alias
UMLS CUI [1]
C0241596
Back to the top of the page

Similar models

openEHR-EHR-CLUSTER.palpation_of_uterus.v1

1 forms
  1. StudyEvent: openEHR-EHR-CLUSTER.palpation_of_uterus.v1
    1. openEHR-EHR-CLUSTER.palpation_of_uterus.v1
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
openEHR-EHR-CLUSTER.palpation_of_uterus.v1.xml
C0042149 (UMLS CUI-1)
C0030247 (UMLS CUI-2)
Palpation of Uterus
Item
Palpation of Uterus
text
C0042149 (UMLS CUI [1,1])
C0030247 (UMLS CUI [1,2])
Clinical Description
Item
Clinical Description
text
C0678257 (UMLS CUI [1,1])
C0205210 (UMLS CUI [1,2])
Item
Position
text
C0425916 (UMLS CUI [1])
Position
Code List
Position
CL Item
Anteverted (1)
CL Item
Upright (2)
CL Item
Retroverted (3)
Fundal Height
Item
Fundal Height
float
C0733755 (UMLS CUI [1,1])
C0227817 (UMLS CUI [1,2])
Gestation
Item
Gestation
text
C1135241 (UMLS CUI [1])
Uterine size
Item
Uterine size
text
C0042149 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
Item
Relative Size
text
C0042149 (UMLS CUI [1,1])
C0456389 (UMLS CUI [1,2])
C0750572 (UMLS CUI [1,3])
Relative Size
Code List
Relative Size
CL Item
Normal size (1)
CL Item
6 weeks gestation (2)
CL Item
8 weeks gestation (3)
CL Item
10 weeks gestation (4)
CL Item
At pubic symphysis (5)
CL Item
At umbilicus (6)
CL Item
At xiphisternum (7)
Item
Liquor Volume
text
C0002638 (UMLS CUI [1])
Liquor Volume
Code List
Liquor Volume
CL Item
Decreased (1)
CL Item
Normal (2)
CL Item
Increased (3)
Number of Fetuses
Item
Number of Fetuses
integer
C0422809 (UMLS CUI [1])
Fetal Detail
Item
Fetal Detail
text
C0521457 (UMLS CUI [1,1])
C1522508 (UMLS CUI [1,2])
Surface
Item
Surface
text
C0205148 (UMLS CUI [1,1])
C0332479 (UMLS CUI [1,2])
C0042149 (UMLS CUI [1,3])
Consistency
Item
Consistency
text
C0332529 (UMLS CUI [1,1])
C0042149 (UMLS CUI [1,2])
Tenderness
Item
Tenderness
text
C0567083 (UMLS CUI [1])
Item
Mobility
text
C0241596 (UMLS CUI [1])
Mobility
Code List
Mobility
CL Item
Mobile (1)
CL Item
Fixed (2)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial