ID

29615

Beschreibung

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/

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_uterus.v1

Englisch

openEHR-EHR-CLUSTER.palpation_of_uterus.v1

1 Formulare  
  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
Beschreibung

openEHR-EHR-CLUSTER.palpation_of_uterus.v1.xml

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

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

Datentyp

text

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

Narrative description of findings on examination of the uterus.

Datentyp

text

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

Position of uterus.

Datentyp

text

Alias
UMLS CUI [1]
C0425916
Fundal Height
Beschreibung

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

Datentyp

float

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

Uterine size estimation, expressed as length of gestation.

Datentyp

text

Alias
UMLS CUI [1]
C1135241
Uterine size
Beschreibung

Measurement or estimation of the size of the uterus.

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

Alias
UMLS CUI [1]
C0002638
Number of Fetuses
Beschreibung

The number of fetuses found on palpation of the uterus.

Datentyp

integer

Alias
UMLS CUI [1]
C0422809
Fetal Detail
Beschreibung

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

Datentyp

text

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

Narrative description of the surface and shape of the uterus.

Datentyp

text

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

Narrative description of the consistency of the uterus.

Datentyp

text

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

Narrative description of any findings of tenderness.

Datentyp

text

Alias
UMLS CUI [1]
C0567083
Mobility
Beschreibung

Mobility of the uterus.

Datentyp

text

Alias
UMLS CUI [1]
C0241596
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Ähnliche Modelle

openEHR-EHR-CLUSTER.palpation_of_uterus.v1

1 Formulare
  1. StudyEvent: openEHR-EHR-CLUSTER.palpation_of_uterus.v1
    1. openEHR-EHR-CLUSTER.palpation_of_uterus.v1
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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)
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