ISO_639-1 en false 2021-11-24 Heather Leslie Atomica Informatics heather.leslie@atomicainformatics.com Vebjørn Arntzen, Oslo University Hospital Liv Laugen, Oslo University Hospital Peter Fedorcsak, Oslo University Hospital in_development 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/. Nasjonal IKT Avgrenet fra: Imaging examination of an adnexal mass, Draft archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2022-06-01]. Available from: https://ckm.openehr.org/ckm/archetypes/1013.1.5939 no.nasjonalikt Nasjonal IKT no.nasjonalikt 599667E8E11C2BD3CFBBA672F4CCC08D 28a22a81-6e6b-40d6-8f2a-cf78f72e414d 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. 0.0.1-alpha

ISO_639-1 de Zur Darstellung der Befunde einer radiologischen Untersuchung einer bestimmten Körperstruktur oder -region und deren Interpretation. Befund, Ergebnis, Bildgebung, Körper, Organ, System, Struktur, Region, Beobachtung, Diagnostik, Radiologie, Bild *Use to record the findings on radiological examination of a specified body structure or region, and their interpretation. In practice, the design intent is for the CLUSTER.imaging_exam family of archetypes to be used to record all detailed findings on radiological examination. The family of specialised archetypes are derived from this generic parent archetype, CLUSTER.imaging_exam, designed as a universal pattern for recording any findings in any specified body structure or region and using any modality. Each structure- or region-specific specialisation of this parent archetype is intended to be inclusive of all reasonably anticipated and relevant findings. For example, the CLUSTER.imaging_exam-ovary will support recording of all findings that would be expected in reporting on imaging of the ovary using any radiological modality, including the size of the ovary, largest follicle size and the diameter and description of specific follicles. Similarly, CLUSTER.imaging_exam-lymph_node_group will contain data elements required to record specific findings of a lymph node group, including its precise or relative location in the body and the number of lymph nodes in the group. If an appropriate specialisation is not available for a body structure or region, this archetype can be used to record all relevant findings related to the structure or region. This archetype and its related family of specialisations are designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result 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 of its specialisations need to be extended with further levels of detailed findings, additional instances of the CLUSTER.imaging_exam or its specialisations can be nested in the 'Additional details' SLOT. (en) Nicht zur Darstellung von Befunden verwenden, die außerhalb der identifizierten Körperstruktur oder -region beobachtet wurden. Verwenden Sie zu diesem Zweck eine separate Instanz eines oder mehrerer Archetypen aus der Familie CLUSTER.imaging_exam. Darf nicht verwendet werden, um Details in Bezug auf die Gesamtbefunde, den Kontext oder technische Details in Bezug auf ein vollständiges Testergebnis einer bildgebenden Untersuchung darzustellen. Verwenden Sie zu diesem Zweck das OBSERVATION.imaging_exam_result. Zum Beispiel Kommentare zur Studienqualität, zu Differenzialdiagnosen und zum Gesamteindruck. © Nasjonal IKT HF

ISO_639-1 nb For å registrere en fritekstbeskrivelse, strukturerte detaljer og klinisk tolkning av observerte funn eller observasjoner ved bildediagnostisk undersøkelse rettet mot en oppfylning i adneks. Brukes for å registrere en fritekstbeskrivelse, strukturerte detaljer og klinisk tolkning av observerte funn eller observasjoner ved bildediagnostisk undersøkelse rettet mot en oppfylning i adneks. Denne arketypen ble utviklet til bruk i SLOT'et "Strukturerte funn" i arketypen OBSERVATION.imaging_exam_result (Bildediagnostisk svar) som vil identifisere kroppsstrukturen som inneholder det morfologiske avviket, men kan også brukes innen andre ENTRY- og CLUSTER-arketyper der det er klinisk passende. Brukes som et rammeverk hvor andre CLUSTER arketyper kan nøstes i SLOT'et "Strukturerte detaljer" for å registrere ytterligere strukturerte billedfunn for delstrukturer eller andre relevante funn. Skal ikke brukes til å registrere funn utenfor det spesifiserte organ eller kroppsdel. Bruk andre arketyper fra gruppen av CLUSTER.imaging_exam-arketyper for dette. Skal ikke brukes til å registrere overordnede undersøkelsesfunn, kontekst eller tekniske detaljer relatert til billedundersøkelsen. Bruk arketypen OBSERVATION.imaging_exam_result (Bildediagnostisk svar) for å registrere for eksempel kommentar om undersøkelseskvalitet, differensialdiagnose og overordnet konklusjon. © Nasjonal IKT HF

ISO_639-1 en To record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting an adnexal mass. Use to record a narrative description, structured details and clinical impression of the findings of a morphological abnormality observed in an imaging examination targeting an adnexal mass. This archetype has been designed to be used in the 'Structured imaging findings' SLOT within the OBSERVATION.imaging_exam_result archetype which will identify the structure containing the morphological abnormality, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Additional details' SLOT within this archetype to record additional nested levels of structured imaging findings for related body substructures or site-specific findings. Not to be used to record findings for a specified body structure or region. Use other archetypes from the CLUSTER.imaging_exam family 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. © Nasjonal IKT HF

ISO_639-1 de Natalia Strauch Medizinische Hochschule Hannover Strauch.Natalia@mh-hannover.de ISO_639-1 nb Peter Fedorcsak, Vebjørn Arntzen University of Oslo, Oslo University Hospital peterfe@uio.no, varntzen@ous-hf.no 0c7dd1ee-ea77-4de6-b037-7aa60d100d9e openEHR-EHR-CLUSTER.imaging_exam-abnormality-adnexal_mass.v0 1.4 at0000.1.1 openEHR-EHR-CLUSTER.imaging_exam-abnormality.v0 CLUSTER true true false false 1 1 at0000.1.1 items true true false false 1 1 ELEMENT true true false false 1 1 at0001.1.1 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0.1 at0.0.1 ELEMENT true true false false 0 1 at0002 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0003 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/} Boolean 2007 false String archetype_id/value attribute C_STRING 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 constraint ELEMENT true true false false 0 1 at0004 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0005 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-abnormality(-[a-zA-Z0-9_]+)*\.v0/} Boolean 2007 false String archetype_id/value attribute C_STRING 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-abnormality(-[a-zA-Z0-9_]+)*\.v0 constraint ELEMENT true false true 0 at0006 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0007 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0.2 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0.3.1 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0.0.2 at0.0.3 at0.0.4 at0.0.5 at0.0.6 at0.0.7 ELEMENT true true false false 0 3 at0.4 value true true false false 0 1 DV_QUANTITY true true false false 1 1 openehr 122 true false true 0.0 true true false false 0 0 mm true false true 0.0 true true false false 1 1 cm ELEMENT true true false false 0 1 at0.9 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0.10 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0.11 value true true false false 0 1 DV_TEXT true true false false 1 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0.12 at0.13 ELEMENT true true false false 0 1 at0.14 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0.15 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0.16 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0.17 at0.18 ELEMENT true true false false 0 1 at0.19 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0.20 value true true false false 0 1 DV_TEXT true true false false 1 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0.21 at0.22 at0.23 at0.24 ELEMENT true true false false 0 3 at0.0.15 value true true false false 0 1 DV_QUANTITY true true false false 1 1 openehr 122 true false true 0.0 true true false false 0 0 mm true false true 0.0 true true false false 1 1 cm ELEMENT true true false false 0 3 at0.0.8 value true true false false 0 1 DV_COUNT true true false false 1 1 magnitude true true false false 1 1 INTEGER true true false false 1 1 true false true 0 ELEMENT true true false false 0 1 at0.0.13 value true true false false 0 1 DV_COUNT true true false false 1 1 magnitude true true false false 1 1 INTEGER true true false false 1 1 true false true 0 ELEMENT true true false false 0 1 at0.0.14 value true true false false 0 1 DV_QUANTITY true true false false 1 1 openehr 122 true false true 0.0 true true false false 0 0 mm false false true false true 1 Adnexal mass An adnexal mass was examined. Number of papillary projections The number of papillary projections in the adnexal mass. Maximal septum width The measured width of the thickest septum. Solid diameter A measured diameter of the largest solid tissue component. This data element has 3 occurrences to allow for 3 measurements in different axes. Unilocular cyst A unilocular cyst without septa, solid parts or papillary structures. Unilocular-solid cyst A unilocular cyst with a measurable solid component or at least one papillary structure. Multilocular cyst A cyst with at least one septum but no measurable solid components or papillary projections. Multilocular-solid cyst A cyst with at least one septum and a measurable solid component or at least one papillary projection. Solid tumour A tumor where the solid components comprise 80% or more of the tumour when assessed in a two-dimensional section. Indeterminate It is not possible to determine the type of mass. Number of cyst locules The number of cyst locules in the adnexal mass. Morphological abnormality A morphological abnormality was examined. Texture The texture of the abnormality. Definition The definition of the abnormality. Well-defined The abnormality is well-defined. Poorly-defined The abnormality is poorly-defined. Contour The contour of the abnormality. Margin The margin of the abnormality. Calcification Presence of calcification in the abnormality. Present Calcification is observed. Absent Calcification is not observed. Effect Narrative description about the effect of the abnormality on surrounding structures. For example: 'pressing on blood vessel'. Label A label for the abnormality. Use to differentiate one abnormality from another when there is more than one present at the same site. Vascularisation Assessment of the blood flow to the abnormality. Often determined by colour doppler or similar. None No blood flow can be detected. Mild Minimal blood flow can be detected. Moderate Moderate blood flow can be detected. Marked Marked blood flow can be detected. Type The type of abnormality. Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy. Type The type of abnormality. Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy. Diameter A measured diameter of the abnormality. This data element has 3 occurrences to allow for 3 measurements in different axes. Diameter A measured diameter of the abnormality. Dimension 1 The measured length of the longest axis of the abnormality. Dimension 2 The measured length of an axis of the abnormality perpendicular to Dimension 1. Dimension 3 The measured length of an axis of the abnormality perpendicular to Dimension 1 and Dimension 2.. Shape The shape of the abnormality. Imaging examination of a body structure Findings on radiological examination of a specified body structure or region. Imaging examination of an abnormality Findings of a morphological abnormality observed in an imaging examination targeting a specified structure or region, using radiographic techniques. Imaging examination of an adnexal mass Findings of a morphological abnormality observed in an imaging examination targeting a mass near the uterus, including the ovaries, fallopian tubes, and connecting tissues, using radiographic techniques. Body structure Identification of the body structure or region examined. For example: 'Liver', 'Right ankle' or 'Lymph node group'. Coding of the body structure with an appropriate terminology, such as SNOMED CT, is recommended. Body structure Identification of the body structure or region examined. Body structure Identification of the body structure or region examined. Body site Identification of the area of the body under examination. 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 Structured details about the area of the body under examination. 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. Imaging findings Narrative description of the imaging findings observed during this examination. Additional details Additional structured details about imaging findings for the identified body structure or region, or findings of related structures. Impression Single word, phrase or brief description that represents the clinical meaning and significance of all imaging findings for the identified body structure. 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 Additional narrative about the imaging findings of the body structure, not captured in other fields. Oppfylning i adneks Undersøkelse av en oppfylning i adneks. Antall papillære utspring Antall papillære utspring i oppfylningen. Største bredde av skilleveggen Den største bredden av skilleveggen. Solid diameter Diameter for den største solide vevskomponenten. Elementet har 3 forekomster for å tillate registrering av målinger i 3 retninger. Enkamret cyste Enkamret cyste uten skillevegg, solide deler eller papillære strukturer. Enkamret-solid cyste En enkamret cyste med målbar solid komponent eller minst en papiller struktur. Flerkamret cyste En cyste med minst en skillevegg, men ingen målbare solide komponenter eller papillære utspring. Flerkamret-solid cyste En cyste med minst en skillevegg og målbar solid komponent eller minst ett papillært utspring. Solid svulst En svulst hvor den solide komponenten utgjør 80% eller mer av svulsten, sett på i et todimensjonalt snitt. Ubestemmelig Det er umulig å bestemme oppfyllingens type. Antall cystiske kamre Antall cystiske kamre i oppfylningen. Morfologisk avvik Undersøkelse av et morfologisk avvik. Tekstur Avvikets tekstur. Avgrensning Avvikets avgrensning. Godt avgrenset Avviket er godt avgrenset. Svakt avgrenset Avviket er svakt avgrenset. Kontur Avvikets kontur. Grenseflate Avvikets grenseflate. Forkalkning Tilstedeværelse av forkalkning i avviket. Tilstede Forkalkning kan sees. Fraværende Forkalkning kan ikke sees. Effekt Fritekstbeskrivelse av avvikets effekt på omkringliggende strukturer. Eksempelvis 'presser mot blodkar'. Identifisering Identifisering eller betegnelse for avviket. Brukes for a skille mellom et avvik fra et annet når flere avvik er tilstede samtidig. Blodforsyning Undersøkelse av avvikets blodforsyning. Undersøkes ofte med fargedoppler eller lignende metode. Ingen Ingen blodforsyning kan sees. Mild Liten blodtilstrømning kan sees. Moderat Moderat blodtilstrømning kan sees. Markert Markert blodtilstrømning kan sees. Type Avvikets type. Det bør om mulig benyttes ekstern terminologi for å angi den morfologisk typen for avvik. Eksempelvis cyste eller knute fra SNOMED 4147007 | Oppfylning (morfologisk avvik) | hierarki. Type Type for avviket. Det bør om mulig benyttes ekstern terminologi for å angi den morfologisk typen for avvik. Eksempelvis cyste eller knute fra SNOMED 4147007 | Oppfylning (morfologisk avvik) | hierarki. Diameter Avvikets diameter. Elementet har 3 forekomster for å tillate registrering av målinger i 3 retninger. *Diameter(en) *A measured diameter of the abnormality.(en) *Dimension 1(en) *The measured length of the longest axis of the abnormality.(en) *Dimension 2(en) *The measured length of an axis of the abnormality perpendicular to Dimension 1.(en) *Dimension 3(en) *The measured length of an axis of the abnormality perpendicular to Dimension 1 and Dimension 2..(en) Form Avvikets form. Bildediagnostisk undersøkelse - kroppsstruktur Funn eller observasjoner ved radiologisk undersøkelse av et definert organ eller en kroppsdel. Bildeundersøkelse av et avvik Funn ved bildeundersøkelse av et morfologisk avvik med bruk av radiologiske metoder rettet mot en spesifisert struktur eller område. Bildediagnostisk undersøkelse - oppfylning i adneks Funn eller observasjoner ved bildeundersøkelse av en oppfylning i livmorens adneks, herunder eggstokk, eggledere og omkringliggende vev, med bruk av radiologiske metoder. Kroppsstruktur Identifisering av organet eller kroppsdelen som svaret gjelder. For eksempel "Lever", "Høyre ankel" eller "Lymfeknutegruppe". Det er anbefalt å kode kroppsstruktur med en passende terminologi, som SNOMED CT. Struktur Navn av undersøkt struktur eller område på eller i kroppen. Struktur Navn av undersøkt struktur eller område på eller i kroppen. Anatomisk lokalisasjon Identifisering av organ eller kroppsdel. 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". Strukturert anatomisk lokalisasjon Strukturerte detaljer om organ eller kroppsdel. 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". Funn Fritekstlig beskrivelse av funn eller observasjoner på bilder tatt under denne undersøkelsen. Ytterligere detaljer Ytterligere strukturerte detaljer om funn eller observasjoner på bilder for det definerte organet eller kroppsdelen, eller om funn eller observasjoner hos tilhørende kroppsstrukturer. Resymé Enkeltord, frase eller kortfattet beskrivelse som uttrykker den kliniske betydningen av alle funn og observasjoner for den definerte kroppsstrukturen. 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. Kommentar Ytterligere fritekst om funn eller observasjoner på bilder av kroppsstrukturen og som ikke er fanget i andre felt. Adnexal mass An adnexal mass was examined. Number of papillary projections The number of papillary projections in the adnexal mass. Maximal septum width The measured width of the thickest septum. Solid diameter A measured diameter of the largest solid tissue component. This data element has 3 occurrences to allow for 3 measurements in different axes. Unilocular cyst A unilocular cyst without septa, solid parts or papillary structures. Unilocular-solid cyst A unilocular cyst with a measurable solid component or at least one papillary structure. Multilocular cyst A cyst with at least one septum but no measurable solid components or papillary projections. Multilocular-solid cyst A cyst with at least one septum and a measurable solid component or at least one papillary projection. Solid tumour A tumor where the solid components comprise 80% or more of the tumour when assessed in a two-dimensional section. Indeterminate It is not possible to determine the type of mass. Number of cyst locules The number of cyst locules in the adnexal mass. Type The type of abnormality. Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy. Diameter A measured diameter of the abnormality. Dimension 1 The measured length of the longest axis of the abnormality. Dimension 2 The measured length of an axis of the abnormality perpendicular to Dimension 1. Dimension 3 The measured length of an axis of the abnormality perpendicular to Dimension 1 and Dimension 2.. Bildgebende Untersuchung einer Körperstruktur Befunde zur radiologischen Untersuchung einer bestimmten Körperstruktur oder -region. Körperstruktur Identifizierung der untersuchten Körperstruktur oder Region. Zum Beispiel: „Leber“, „Rechtes Fußgelenk“ oder „Lymphknotengruppe“. Es wird empfohlen, die Körperstruktur mit einer geeigneten Terminologie, wie z. B. SNOMED CT, zu codieren. Zusätzliche Angaben Zusätzliche strukturierte Angaben zu bildgebenden Befunden für die identifizierte Körperstruktur oder -region oder befundbezogene Strukturen. Bildgebende Untersuchung einer Körperstruktur Befunde zur radiologischen Untersuchung einer bestimmten Körperstruktur oder -region. Kommentar Zusätzlicher Text über die bildgebenden Befunde der Körperstruktur, der in anderen Bereichen nicht erfasst wurde. Körperstruktur Identifizierung der untersuchten Körperstruktur oder Region. Zum Beispiel: „Leber“, „Rechtes Fußgelenk“ oder „Lymphknotengruppe“. Es wird empfohlen, die Körperstruktur mit einer geeigneten Terminologie, wie z. B. SNOMED CT, zu codieren. Körperstelle strukturiert Strukturierte Angaben zum untersuchten Körperbereich. 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. Interpretation Einzelnes Wort, Satz oder kurze Beschreibung, die die klinische Bedeutung und Signifikanz aller bildgebenden Befunde für die identifizierte Körperstruktur darstellt. 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. Körperstelle Identifizierung des zu untersuchenden Bereichs des Körpers. 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. Morphological abnormality A morphological abnormality was examined. Texture The texture of the abnormality. Definition The definition of the abnormality. Well-defined The abnormality is well-defined. Poorly-defined The abnormality is poorly-defined. Contour The contour of the abnormality. Margin The margin of the abnormality. Calcification Presence of calcification in the abnormality. Present Calcification is observed. Absent Calcification is not observed. Effect Narrative description about the effect of the abnormality on surrounding structures. For example: 'pressing on blood vessel'. Label A label for the abnormality. Use to differentiate one abnormality from another when there is more than one present at the same site. Vascularisation Assessment of the blood flow to the abnormality. Often determined by colour doppler or similar. None No blood flow can be detected. Mild Minimal blood flow can be detected. Moderate Moderate blood flow can be detected. Marked Marked blood flow can be detected. Type The type of abnormality. Coding of the morphological type with an external terminology is preferred, where possible. For example, a cyst or nodule from the SNOMED 4147007 | Mass (morphologic abnormality) | hierarchy. Diameter A measured diameter of the abnormality. This data element has 3 occurrences to allow for 3 measurements in different axes. Shape The shape of the abnormality. Bildgebende Untersuchung einer Körperstruktur Befunde zur radiologischen Untersuchung einer bestimmten Körperstruktur oder -region. Körperstruktur Identifizierung der untersuchten Körperstruktur oder Region. Zum Beispiel: „Leber“, „Rechtes Fußgelenk“ oder „Lymphknotengruppe“. Es wird empfohlen, die Körperstruktur mit einer geeigneten Terminologie, wie z. B. SNOMED CT, zu codieren. Bildgebende Befunde Beschreibung der bei dieser Untersuchung beobachteten bildgebenden Befunde. SNOMED-CT 445039006 SNOMED-CT 49755003