ARCHETYPE Palpation of Uterus (openEHR-EHR-CLUSTER.palpation_of_uterus.v0)

Name: Palpation of Uterus
License: http://creativecommons.org/licenses/by-sa/4.0/

ARCHETYPE ID	openEHR-EHR-CLUSTER.palpation_of_uterus.v0
Concept	Palpation of Uterus
Description	Examination of the uterus by palpation, using either an abdominal or vaginal approach.
Use	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.
Misuse	Not to be used to record examination findings on palpation of an individual fetus. Specific examination findings about the fetus should be recorded in CLUSTER.palpation_of_fetus, which can be nested inside this archetype, within the 'Fetal Detail' SLOT.
Purpose	Record clinical examination findings on palpation of the uterus, either from an abdominal or vaginal approach.
References	openEHR Clinical Knowledge Manager [Internet]. London: openEHR Foundation. [Draft CLUSTER archetype] Examination of the uterus; [authored 2007 Apr 19, cited 2011 Aug 12]. Available from : http://www.openehr.org/knowledge/OKM.html#showArchetype_1013.1.230_4.
Copyright	© Nasjonal IKT HF
Authors	Forfatternavn: Sam Heard Organisasjon: Ocean Informatics E-post: sam.heard@oceaninformatics.com Opprinnelig skrevet dato: 2007- 04-08
Other Details Language	Forfatternavn: Sam Heard Organisasjon: Ocean Informatics E-post: sam.heard@oceaninformatics.com Opprinnelig skrevet dato: 2007- 04-08
Other Details (Language Independent)	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: openEHR Clinical Knowledge Manager [Internet]. London: openEHR Foundation. [Draft CLUSTER archetype] Examination of the uterus; [authored 2007 Apr 19, cited 2011 Aug 12]. Available from : http://www.openehr.org/knowledge/OKM.html#showArchetype_1013.1.230_4. Original Namespace: no.nasjonalikt Original Publisher: Nasjonal IKT Custodian Namespace: no.nasjonalikt MD5-CAM-1.0.1: CB7ED6A93B14672CF112536A49AAD41B Build Uid: e23cfd52-6c5d-4eae-9ae7-21aa7a3ef845 Revision: 0.0.1-alpha
Keywords	uterus, fetus, foetus, baby, abdominally, vaginally
Lifecycle	in_development
UID	b3d97d8e-69b3-4d12-abef-6153bc6b2d25
Language used	en
Citeable Identifier	1078.36.182
Revision Number	0.0.1-alpha
items
Clinical Description	Clinical Description: Narrative description of findings on examination of the uterus.
Uterine size	Uterine size: Measurement or estimation of the size of the uterus.
Fundal Height	Fundal Height: The height of the uterine fundus measured from the symphysis pubis. Usually recorded in pregnancy after approximately 20 weeks of gestation. Egenskap: Length Enheter: 0.0..100.0 cm 0.0..100.0 in
Gestation	Gestation: Uterine size estimation, expressed as length of gestation. Tillatte verdier: uker 0 uker..50 uker
Relative Size	Relative Size: Estimated size of the uterus relative to commonly used anatomical markers, estimations of pregnancy gestation (even if non-pregnant) or common objects. at0026::Normal size [Uterus is approximately the size of a plum or a normal, non-pregnant uterus.] at0025::6 weeks gestation [Uterus is slightly enlarged - approximately equivalent to the size of a pregnant uterus at 6 weeks gestation.] at0024::8 weeks gestation [Uterus is moderately enlarged - approximately equivalent to the size of a pregnant uterus at 8 weeks gestation.] at0023::10 weeks gestation [Uterus is obviously enlarged - approximately equivalent to the size of a grapefruit or a pregnant uterus of 10 weeks gestation.] at0009::At pubic symphysis [The fundus of the uterus is just palpable above the pubic symphysis on abdominal examination, and approximately equivalent to the size of a pregnant uterus at 12 weeks.] at0010::At umbilicus [The fundus of the uterus is palpable at, or about, the level of the umbilicus.] at0011::At xiphisternum [The fundus of the uterus is palpable at, or about, the xiphisternum.]
Position	Position: Position of uterus. at0003::Anteverted [Uterine fundus is tipped forward.] at0038::Upright [Uterine fundus is neither anteverted nor retroverted.] at0004::Retroverted [Uterine fundus is tipped backward.]
Mobility	Mobility: Mobility of the uterus. Consistent with SNOMED values. at0036::Mobile [Uterus is moveable.] at0037::Fixed [Uterus is fixed and immobile.]
Surface	Surface: Narrative description of the surface and shape of the uterus.
Tenderness	Tenderness: Narrative description of any findings of tenderness. True if the uterus is tender. Not to include tenderness of the adnexae or cervix or pelvic region in general.
Consistency	Consistency: Narrative description of the consistency of the uterus.
Liquor Volume	Liquor Volume: Assessment of the relative amount of liquor present in the uterus. at0014::Decreased [The amount of liquor appears reduced; less than expected for gestation.] at0016::Normal [The amount of liquor appears normal; as expected for gestation.] at0018::Increased [The amount of liquor appears increased; more than expected for gestation.]
Number of Fetuses	Number of Fetuses: The number of fetuses found on palpation of the uterus. min: >=0
Fetal Detail	Fetal Detail: Detailed information about the fetus. Record details about each fetus in a multiple birth separately. Inkluder: openEHR-EHR-CLUSTER.palpation_of_fetus.v1 og spesialiseringer
Other contributors	Rita Apelt, Department of Health,NT, Australia Stephen Chu, NEHTA, Australia Margaret Cotter, AMSANT, Australia Tim Garden, NTG Department of Health, Australia Tanya Gardner, CAAC, Australia Sam Heard, Ocean Informatics, Australia (Editor) Heather Leslie, Ocean Informatics, Australia (Editor) Hugh Leslie, Ocean Informatics, Australia Chunlan Ma, Ocean Informatics, Australia Ian McNicoll, Ocean Informatics UK, United Kingdom Jeremy Oats, NT Health, Australia Jo Wright, NT Dept of Health, Australia (Editor)
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