type: resource-definitionsresource: BodyStructure

BodyStructure Definitions

BodyStructure

Specific and identified anatomical structure

Definition: Record details about an anatomical structure. This resource may be used when a coded concept does not provide the necessary detail needed for the use case.

Aliases: anatomical location

Cardinality: 0..*

Mappings: rim=Act; openehr=Archetype ID openEHR-EHR-CLUSTER.anatomical_location.v1 Concept name Anatomical Location Concept description Record details about an anatomical location. Keywords location, site, anatomical Copyright © openEHR Foundation Purpose To record details about anatomical location. Misuse Not for specifiying unilateral/bilateral occurrence - this is related to an evaluation which perhaps includes multiple locations. Author Author name: Heather Leslie Organization: Ocean Informatics Email: heather.leslie@oceaninformatics.com Date of Origination: 2008-11-10 Translator Norwegian Bokmål: Lars Bitsch-Larsen, Haukeland University Hospital of Bergen, Norway, MD, DEAA, MBA, spec in anesthesia, spec in tropical medicine. Arabic (Syria): Mona Saleh Other contributors Heather Leslie, Ocean Informatics, Australia (Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (Editor) Dunmail Hodkinson, Black Pear Software Ltd, UK References Use cases: - 5LICS, midclavicular line - L forearm, 2cm anterior to the cubital fossa - Right iliac fossa - 5 cm below L tibial tuberosity - 2 cm medial to R nipple - 4 cm below R costal margin in midclavicular line - R femur - midline nose - medial aspect of R great toe nail.; w5=clinical.diagnostics

BodyStructure.identifier

Bodystructure identifier

Definition: Identifier for this instance of the anatomical structure.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: w5=FiveWs.identifier; rim=.id; openehr=Specific location Cluster Optional (0..1) Cardinality: Mandatory, repeating, unordered (1..*)

BodyStructure.active

Whether this record is in active use

Definition: Whether this body site is in active use.

Comments: This element is labeled as a modifier because it may be used to mark that the resource was created in error.

Requirements: Need to be able to mark a body site entry as not to be used because it was created in error.

Meaning if Missing: This resource is generally assumed to be active if no value is provided for the active element

Cardinality: 0..1

Type: boolean

Summary: true

Is Modifier: true (Reason: This element is labelled as a modifier because it is a status element that can indicate that a record should not be treated as valid)

Mappings: w5=FiveWs.status; rim=statusCode

BodyStructure.includedStructure

Included anatomic location(s)

Definition: The anatomical location(s) or region(s) of the specimen, lesion, or body structure.

Cardinality: 1..*

Type: BackboneElement

BodyStructure.includedStructure.structure

Code that represents the included structure

Definition: Code that represents the included structure.

Cardinality: 1..1

Type: CodeableConcept

Binding: example:body-site

Summary: true

Mappings: w5=FiveWs.what[x]; v2=OBX-20/SPM-8/SPM-10; rim=.targetSiteCode; openehr=Name of location; dicom=Body Part Examined (0018,0015) or Anatomic Region Sequence (0008,2218)

BodyStructure.includedStructure.laterality

Code that represents the included structure laterality

Definition: Code that represents the included structure laterality.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:bodystructure-laterality

Mappings: w5=FiveWs.what[x]; v2=No distinct element defined in V2.x. The IHE Radiology Technical Framework directs the use of OBR-15-specimen source to contain laterality for imaging studies./SPM-9; rim=.targetSiteCode; openehr=Combines Side, Numerical identifier, Anatomical plane,and Aspect; dicom=Laterality (0020,0060)

BodyStructure.includedStructure.bodyLandmarkOrientation

Landmark relative location

Definition: Body location in relation to a specific body landmark (e.g., a body structure such a navel, scar, or implanted device).

Cardinality: 0..*

Type: BackboneElement

BodyStructure.includedStructure.bodyLandmarkOrientation.landmarkDescription

Explanation of landmark

Definition: Body landmark description used as a reference to locate something else.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:body-site

Mappings: w5=FiveWs.what[x]

BodyStructure.includedStructure.bodyLandmarkOrientation.clockFacePosition

Clockface orientation

Definition: An description of the direction away from a landmark something is located based on a radial clock dial.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:bodystructure-bodylandmarkorientation-clockface-position

Mappings: w5=FiveWs.what[x]

BodyStructure.includedStructure.bodyLandmarkOrientation.distanceFromLandmark

Landmark relative location

Definition: The distance in centimeters a certain observation is made from a body landmark.

Cardinality: 0..*

Type: BackboneElement

BodyStructure.includedStructure.bodyLandmarkOrientation.distanceFromLandmark.device

Measurement device

Definition: An instrument, tool, analyzer, etc. used in the measurement.

Cardinality: 0..*

Type: CodeableReference

Binding: example:device-type

Mappings: w5=FiveWs.what[x]

BodyStructure.includedStructure.bodyLandmarkOrientation.distanceFromLandmark.value

Measured distance from body landmark

Definition: The measured distance (e.g., in cm) from a body landmark.

Cardinality: 0..*

Type: Quantity

BodyStructure.includedStructure.bodyLandmarkOrientation.surfaceOrientation

Relative landmark surface orientation

Definition: The surface area a body location is in relation to a landmark.

Cardinality: 0..*

Type: CodeableConcept

Binding: preferred:bodystructure-relative-location

Mappings: w5=FiveWs.what[x]

BodyStructure.includedStructure.spatialReference

Cartesian reference for structure

Definition: XY or XYZ-coordinate orientation for structure.

Cardinality: 0..*

Type: Reference(ImagingSelection)

Mappings: w5=FiveWs.where[x]

BodyStructure.includedStructure.image

Image(s) of structural aspects

Definition: Image(s) used to identify aspects of an included or excluded structure.

Cardinality: 0..*

Type: Attachment

Summary: false

BodyStructure.includedStructure.qualifier

Code that represents the included structure qualifier

Definition: Code that represents the included structure qualifier.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:bodystructure-relative-location

BodyStructure.includedStructure.morphology

Kind of Structure

Definition: The kind of structure being represented by the body structure at BodyStructure.location. This can define both normal and abnormal morphologies.

Comments: The minimum cardinality of 0 supports the use case of specifying a location without defining a morphology.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:bodystructure-code

Summary: true

Mappings: w5=FiveWs.what[x]; v2=SPM-4/SPM-5

BodyStructure.excludedStructure

Excluded anatomic locations(s)

Definition: The anatomical location(s) or region(s) not occupied or represented by the specimen, lesion, or body structure.

Cardinality: 0..*

BodyStructure.description

Text description

Definition: A summary, characterization or explanation of the body structure.

Comments: This description could include any visual markings used to orientate the viewer e.g. external reference points, special sutures, ink markings.

Cardinality: 0..1

Type: markdown

Summary: true

Mappings: w5=FiveWs.what[x]; v2=NTE; rim=.text; openehr=Description of anatomical location/Visual markings/orientation

BodyStructure.image

Attached images

Definition: Image(s) used to identify aspects of the overall structure.

Cardinality: 0..*

Type: Attachment

Mappings: w5=FiveWs.what[x]; v2=OBX; rim=outboundRelationship[typeCode=COMP].target; openehr=Image

BodyStructure.patient

Who this is about

Definition: The person to which the body site belongs.

Cardinality: 1..1

Type: Reference(Patient)

Summary: true

Mappings: w5=FiveWs.subject; v2=PID-3; rim=.scoper or .scoper.playsRole