open_ehr 0.6.1 → 0.9.0

data/spec/lib/open_ehr/parser/adl/openEHR-EHR-CLUSTER.exam-fetus.v1.adl

@@ -0,0 +1,577 @@
+archetype (adl_version=1.4)
+	openEHR-EHR-CLUSTER.exam-fetus.v1
+specialize
+	openEHR-EHR-CLUSTER.exam.v1
+
+concept
+	[at0000.1]	-- Examination of the fetus
+language
+	original_language = <[ISO_639-1::en]>
+description
+	original_author = <
+		["name"] = <"unknown">
+	>
+	details = <
+		["en"] = <
+			language = <[ISO_639-1::en]>
+			purpose = <"For recording findings on physical examination relating to the fetus while in the uterus">
+			use = <"">
+			keywords = <"foetus", "fetal", "foetal">
+			misuse = <"">
+		>
+	>
+	lifecycle_state = <"Initial">
+	other_contributors = <>
+
+definition
+	CLUSTER[at0000.1] matches {	-- Examination of the fetus
+		items cardinality matches {0..*; unordered} matches {
+			CLUSTER[at0004] occurrences matches {0..1} matches {	-- Normal statements
+				items cardinality matches {0..*; unordered} matches {
+					ELEMENT[at0005] occurrences matches {0..*} matches {	-- Normal statement
+						value matches {
+							DV_TEXT matches {*}
+						}
+					}
+				}
+			}
+			ELEMENT[at0002] occurrences matches {0..1} matches {	-- Clinical description
+				value matches {
+					DV_TEXT matches {*}
+				}
+			}
+			CLUSTER[at0008] occurrences matches {0..1} matches {	-- Findings
+				items cardinality matches {0..*; unordered} matches {
+					ELEMENT[at0.4] occurrences matches {0..1} matches {	-- Lie of the fetus
+						value matches {
+							DV_CODED_TEXT matches {
+								defining_code matches {
+									[local::
+									at0.5, 	-- Longitudinal
+									at0.6, 	-- Transverse
+									at0.7]	-- Oblique
+								}
+							}
+						}
+					}
+					ELEMENT[at0.8] occurrences matches {0..1} matches {	-- Presentation
+						value matches {
+							DV_CODED_TEXT matches {
+								defining_code matches {
+									[local::
+									at0.9, 	-- Cephalic
+									at0.10, 	-- Breech
+									at0.11, 	-- Full breech
+									at0.12, 	-- Extended breech
+									at0.13, 	-- Shoulder
+									at0.69, 	-- Footling breech
+									at0.70, 	-- Face
+									at0.71, 	-- Cord
+									at0.72]	-- Compound
+								}
+							}
+						}
+					}
+					ELEMENT[at0.42] occurrences matches {0..1} matches {	-- Position
+						value matches {
+							DV_CODED_TEXT matches {
+								defining_code matches {
+									[local::
+									at0.43, 	-- Right Occipito-transverse
+									at0.44, 	-- Right Occipito-anterior
+									at0.45, 	-- Right Occipito-posterior
+									at0.46, 	-- Occipito-anterior
+									at0.47, 	-- Occipito-posterior
+									at0.48, 	-- Left Occipito-transverse
+									at0.49, 	-- Left Occipito-anterior
+									at0.50, 	-- Left Occipito-posterior
+									at0.51, 	-- Right Sacro-transverse
+									at0.52, 	-- Right Sacro-anterior
+									at0.53, 	-- Right Sacro-posterior
+									at0.54, 	-- Sacro-Anterior
+									at0.55, 	-- Sacro-Posterior
+									at0.56, 	-- Left Sacro-transverse
+									at0.57, 	-- Left Sacro-anterior
+									at0.58, 	-- Left Sacro-posterior
+									at0.59, 	-- Right Mento-transverse
+									at0.60, 	-- Right Mento-anterior
+									at0.61, 	-- Right Mento-posterior
+									at0.62, 	-- Mento-Anterior
+									at0.63, 	-- Mento-Posterior
+									at0.64, 	-- Left Mento-transverse
+									at0.65, 	-- Left Mento-anterior
+									at0.61]	-- Right Mento-posterior
+								}
+							}
+						}
+					}
+					ELEMENT[at0.32] occurrences matches {0..1} matches {	-- Attitude
+						value matches {
+							DV_CODED_TEXT matches {
+								defining_code matches {
+									[local::
+									at0.33, 	-- Flexed
+									at0.34, 	-- Deflexed
+									at0.35]	-- Extended
+								}
+							}
+						}
+					}
+					CLUSTER[at0.74] occurrences matches {0..1} matches {	-- Engagement
+						items cardinality matches {0..*; unordered} matches {
+							ELEMENT[at0.22] occurrences matches {0..1} matches {	-- Fifths
+								value matches {
+									DV_CODED_TEXT matches {
+										defining_code matches {
+											[local::
+											at0.23, 	-- Not engaged (0/5)
+											at0.24, 	-- 1/5
+											at0.25, 	-- 2/5
+											at0.26, 	-- 3/5
+											at0.27, 	-- 4/5
+											at0.28]	-- Fully engaged (5/5)
+										}
+									}
+								}
+							}
+							ELEMENT[at0.75] occurrences matches {0..1} matches {	-- Qualitative
+								value matches {
+									DV_CODED_TEXT matches {
+										defining_code matches {
+											[local::
+											at0.76, 	-- High and mobile
+											at0.77, 	-- At pelvic brim
+											at0.78]	-- Engaged
+										}
+									}
+								}
+							}
+						}
+					}
+					ELEMENT[at0.14] occurrences matches {0..1} matches {	-- Size relative to gestation
+						value matches {
+							DV_CODED_TEXT matches {
+								defining_code matches {
+									[local::
+									at0.15, 	-- Small for dates
+									at0.67, 	-- ? small for dates
+									at0.16, 	-- Normal
+									at0.68, 	-- ? large for dates
+									at0.17]	-- Large for dates
+								}
+							}
+						}
+					}
+					ELEMENT[at0.29] occurrences matches {0..1} matches {	-- Station
+						value matches {
+							C_DV_QUANTITY <
+								property = <[openehr::122]>
+								list = <
+									["1"] = <
+										units = <"cm">
+										magnitude = <|-5.0..5.0|>
+										precision = <|0|>
+									>
+								>
+							>
+						}
+					}
+					ELEMENT[at0.18] occurrences matches {0..1} matches {	-- Estimated fetal weight
+						value matches {
+							C_DV_QUANTITY <
+								property = <[openehr::124]>
+								list = <
+									["1"] = <
+										units = <"kg">
+										magnitude = <|0.0..20.0|>
+									>
+									["2"] = <
+										units = <"gm">
+										magnitude = <|0.0..20000.0|>
+										precision = <|0|>
+									>
+								>
+							>
+						}
+					}
+					CLUSTER[at0007] occurrences matches {0..1} matches {	-- Size
+						items cardinality matches {0..*; unordered} matches {
+							allow_archetype CLUSTER occurrences matches {0..1} matches {
+								include
+									archetype_id/value matches {/dimensions\.v1/}
+									archetype_id/value matches {/size\.v1draft/}
+							}
+						}
+					}
+					CLUSTER[at0003] occurrences matches {0..1} matches {	-- Detail
+						items cardinality matches {0..*; unordered} matches {
+							allow_archetype CLUSTER occurrences matches {0..1} matches {
+								include
+									archetype_id/value matches {/exam\.v1/}
+							}
+						}
+					}
+				}
+			}
+			ELEMENT[at0006] occurrences matches {0..*} matches {	-- Image
+				value matches {
+					DV_MULTIMEDIA matches {
+						media_type matches {
+							[openEHR::
+							426, 
+							427, 
+							429]
+						}
+					}
+				}
+			}
+		}
+	}
+
+ontology
+	term_definitions = <
+		["en"] = <
+			items = <
+				["at0.10"] = <
+					description = <"The breech is the presenting part">
+					text = <"Breech">
+				>
+				["at0.11"] = <
+					description = <"The breech is presenting with the legs flexed">
+					text = <"Full breech">
+				>
+				["at0.12"] = <
+					description = <"The breech is the presenting part with the leg(s) extended">
+					text = <"Extended breech">
+				>
+				["at0.13"] = <
+					description = <"The shoulder is the presenting part">
+					text = <"Shoulder">
+				>
+				["at0.14"] = <
+					description = <"The apparent size of the baby relative to normal for gestation">
+					text = <"Size relative to gestation">
+				>
+				["at0.15"] = <
+					description = <"The size of the baby is smaller than expected for gestation">
+					text = <"Small for dates">
+				>
+				["at0.16"] = <
+					description = <"The size of the baby is normal for gestation">
+					text = <"Normal">
+				>
+				["at0.17"] = <
+					description = <"The size of the baby is larger than expected for gestation">
+					text = <"Large for dates">
+				>
+				["at0.18"] = <
+					description = <"The estimated weight of the baby on examination">
+					text = <"Estimated fetal weight">
+				>
+				["at0.19"] = <
+					description = <"The position of the head in relation to the pelvis">
+					text = <"Denominator">
+				>
+				["at0.20"] = <
+					description = <"The occiput is anterior rotated to the anterior">
+					text = <"Left occipito-anterior">
+				>
+				["at0.21"] = <
+					description = <"The occiput is at the back">
+					text = <"Occipito-posterior">
+				>
+				["at0.22"] = <
+					description = <"The proportion of the presenting part which is felt above the pelvis">
+					text = <"Fifths">
+				>
+				["at0.23"] = <
+					description = <"The head is not engaged in the pelvis">
+					text = <"Not engaged (0/5)">
+				>
+				["at0.24"] = <
+					description = <"About 20% of the head is inside the pelvis">
+					text = <"1/5">
+				>
+				["at0.25"] = <
+					description = <"About 40% of the head is inside the pelvis">
+					text = <"2/5">
+				>
+				["at0.26"] = <
+					description = <"About 60% of the head is inside the pelvis">
+					text = <"3/5">
+				>
+				["at0.27"] = <
+					description = <"About 80% of the head is inside the pelvis">
+					text = <"4/5">
+				>
+				["at0.28"] = <
+					description = <"The head is inside the pelvis">
+					text = <"Fully engaged (5/5)">
+				>
+				["at0.29"] = <
+					description = <"Posiiton relative to the ischial spines (minus is above, 0 is at the spines and plus is below)">
+					text = <"Station">
+				>
+				["at0.30"] = <
+					description = <"The occiput is adjacent to the symphasis pubis">
+					text = <"Occipito-anterior">
+				>
+				["at0.31"] = <
+					description = <"The occiput is anterior rotated to the right">
+					text = <"Right occipito-anterior">
+				>
+				["at0.32"] = <
+					description = <"The degree of flexion of the body">
+					text = <"Attitude">
+				>
+				["at0.33"] = <
+					description = <"The fetus is fully flexed">
+					text = <"Flexed">
+				>
+				["at0.34"] = <
+					description = <"The fetus is not flexed">
+					text = <"Deflexed">
+				>
+				["at0.35"] = <
+					description = <"The fetus is extended">
+					text = <"Extended">
+				>
+				["at0.36"] = <
+					description = <"The occiput is on the left">
+					text = <"Left occipito-transverse">
+				>
+				["at0.37"] = <
+					description = <"The occiput is on the right">
+					text = <"Right occipito-transverse">
+				>
+				["at0.38"] = <
+					description = <"*">
+					text = <"Position">
+				>
+				["at0.39"] = <
+					description = <"The occipital bone">
+					text = <"Occipito">
+				>
+				["at0.4"] = <
+					description = <"The position of the fetus">
+					text = <"Lie of the fetus">
+				>
+				["at0.40"] = <
+					description = <"The chin">
+					text = <"Mento">
+				>
+				["at0.41"] = <
+					description = <"The sacral bone">
+					text = <"Sacro">
+				>
+				["at0.42"] = <
+					description = <"The orientation of the denominator">
+					text = <"Position">
+				>
+				["at0.43"] = <
+					description = <"The occiput is towards the right">
+					text = <"Right Occipito-transverse">
+				>
+				["at0.44"] = <
+					description = <"The occiput is towards the right and anterior">
+					text = <"Right Occipito-anterior">
+				>
+				["at0.45"] = <
+					description = <"The occiput is to the right and posterior">
+					text = <"Right Occipito-posterior">
+				>
+				["at0.46"] = <
+					description = <"The occiput is towards the symphasis">
+					text = <"Occipito-anterior">
+				>
+				["at0.47"] = <
+					description = <"The occiput is towards the sacrum">
+					text = <"Occipito-posterior">
+				>
+				["at0.48"] = <
+					description = <"The occiput is towards the left">
+					text = <"Left Occipito-transverse">
+				>
+				["at0.49"] = <
+					description = <"The occiput is to the left and symphasis">
+					text = <"Left Occipito-anterior">
+				>
+				["at0.5"] = <
+					description = <"The lie is along the line of the mother's spine">
+					text = <"Longitudinal">
+				>
+				["at0.50"] = <
+					description = <"The occiput is to the left and posterior">
+					text = <"Left Occipito-posterior">
+				>
+				["at0.51"] = <
+					description = <"The fetal sacrum is towards the right">
+					text = <"Right Sacro-transverse">
+				>
+				["at0.52"] = <
+					description = <"The fetal sacrum is towards the right and anterior">
+					text = <"Right Sacro-anterior">
+				>
+				["at0.53"] = <
+					description = <"The fetal sacrum is to the right and posterior">
+					text = <"Right Sacro-posterior">
+				>
+				["at0.54"] = <
+					description = <"The fetal sacrum is towards the symphasis">
+					text = <"Sacro-Anterior">
+				>
+				["at0.55"] = <
+					description = <"The fetal sacrum is towards the sacrum">
+					text = <"Sacro-Posterior">
+				>
+				["at0.56"] = <
+					description = <"The fetal sacrum is towards the left">
+					text = <"Left Sacro-transverse">
+				>
+				["at0.57"] = <
+					description = <"The fetal sacrum is to the left and symphasis">
+					text = <"Left Sacro-anterior">
+				>
+				["at0.58"] = <
+					description = <"The fetal sacrum is to the left and posterior">
+					text = <"Left Sacro-posterior">
+				>
+				["at0.59"] = <
+					description = <"The fetal chin is towards the right">
+					text = <"Right Mento-transverse">
+				>
+				["at0.6"] = <
+					description = <"The lie is perpendicular to the mother's spine">
+					text = <"Transverse">
+				>
+				["at0.60"] = <
+					description = <"The fetal chin is towards the right and anterior">
+					text = <"Right Mento-anterior">
+				>
+				["at0.61"] = <
+					description = <"The fetal chin is to the right and posterior">
+					text = <"Right Mento-posterior">
+				>
+				["at0.62"] = <
+					description = <"The fetal chin is towards the symphasis">
+					text = <"Mento-Anterior">
+				>
+				["at0.63"] = <
+					description = <"The fetal chin is towards the sacrum">
+					text = <"Mento-Posterior">
+				>
+				["at0.64"] = <
+					description = <"The fetal chin is towards the left">
+					text = <"Left Mento-transverse">
+				>
+				["at0.65"] = <
+					description = <"The fetal chin is to the left and symphasis">
+					text = <"Left Mento-anterior">
+				>
+				["at0.66"] = <
+					description = <"The fetal chin is to the left and posterior">
+					text = <"Left Mento-posterior">
+				>
+				["at0.67"] = <
+					description = <"Possibly small for this gestation">
+					text = <"? small for dates">
+				>
+				["at0.68"] = <
+					description = <"Possibly larger than expected for this gestation">
+					text = <"? large for dates">
+				>
+				["at0.69"] = <
+					description = <"A fetal foot is extended and presenting">
+					text = <"Footling breech">
+				>
+				["at0.7"] = <
+					description = <"The lie is oblique to the mother's spine">
+					text = <"Oblique">
+				>
+				["at0.70"] = <
+					description = <"The head is extended and the face is presenting">
+					text = <"Face">
+				>
+				["at0.71"] = <
+					description = <"The umbilical cord is presenting">
+					text = <"Cord">
+				>
+				["at0.72"] = <
+					description = <"There is a compound presentation">
+					text = <"Compound">
+				>
+				["at0.73"] = <
+					description = <"*">
+					text = <"Station">
+				>
+				["at0.74"] = <
+					description = <"Estimation of presenting part in relation to pelvic brim">
+					text = <"Engagement">
+				>
+				["at0.75"] = <
+					description = <"Description of engagement of fetal head">
+					text = <"Qualitative">
+				>
+				["at0.76"] = <
+					description = <"*">
+					text = <"High and mobile">
+				>
+				["at0.77"] = <
+					description = <"*">
+					text = <"At pelvic brim">
+				>
+				["at0.78"] = <
+					description = <"*">
+					text = <"Engaged">
+				>
+				["at0.79"] = <
+					description = <"*">
+					text = <"Estimation">
+				>
+				["at0.8"] = <
+					description = <"The presenting part of the fetus">
+					text = <"Presentation">
+				>
+				["at0.9"] = <
+					description = <"The head is the presenting part">
+					text = <"Cephalic">
+				>
+				["at0000"] = <
+					description = <"Generic examination cluster for describing a finding on physical examination">
+					text = <"Examination">
+				>
+				["at0000.1"] = <
+					description = <"Examination cluster for describing a finding on physical examination of a fetus">
+					text = <"Examination of the fetus">
+				>
+				["at0002"] = <
+					description = <"Textural description of the part examined">
+					text = <"Clinical description">
+				>
+				["at0003"] = <
+					description = <"More focused examination findings">
+					text = <"Detail">
+				>
+				["at0004"] = <
+					description = <"A group of statements about the normality of the examination">
+					text = <"Normal statements">
+				>
+				["at0005"] = <
+					description = <"A specific statement of normality">
+					text = <"Normal statement">
+				>
+				["at0006"] = <
+					description = <"Drawing or image of the area examined">
+					text = <"Image">
+				>
+				["at0007"] = <
+					description = <"Information about the size of the object for examination">
+					text = <"Size">
+				>
+				["at0008"] = <
+					description = <"Clinical findings">
+					text = <"Findings">
+				>
+			>
+		>
+	>