| |
 Normal statements, A group of statements about the normality of the examination. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
 Normal statement |
A specific statement of normality | Text
| optional, repeating
0..* |
Free or coded text |
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
| Clinical description |
Textural description of the part examined | Text
| optional
0..1 |
Free or coded text |
| Findings, Clinical findings. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Position |
The position in relation to the normal anatomical position | Coded text
| optional
0..1 |
Central
To the right
To the left
Anterior
Posterior |
| Consistency |
Consistency of cervix | Coded text
| optional
0..1 |
Soft
Firm |
| Size, Information about the size of the object for examination. Cluster (0..1) optional |
| |
Slot |
Type |
Occurrences |
Constraints |
 |
CLUSTER |
0..* |
Include entries
|
|
|
|
| Labour-specific findings, *. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
 Effacement |
The effacement of the uterine cervix in late pregnancy or labour. | Ordinal
| optional
0..1 |
0, Uneffaced
5, Ripe
10, 10% effaced
20, 20% effaced
30, 30% effaced
40, 40% effaced
50, Partially (50%) effaced
60, 60% effaced
70, 70% effaced
80, 80% effaced
90, 90% effaced
100, Fully effaced |
| Thickness |
Cervical thickness | Coded text
| optional
0..1 |
Thick
Thin
Paper-thin
Oedematous |
| Application to presenting part |
Application of cervix to fetal presenting part | Coded text
| optional
0..1 |
Loosely applied
Tightly applied |
| Cervical os, The outlet of the uterus. Cluster (0..2) optional, repeating |
| |
Concept |
Description |
Type |
Cardinality |
Values |
| Site |
Identify part of cervix which is being examined | Coded text
| optional
0..1 |
External os
Internal os |
| Dilation, Dilation of cervix. Cluster (0..1) optional |
| |
Concept |
Description |
Type |
Cardinality |
Values |
 Estimate |
The dilation of the os | Quantity
| optional
0..1 |
Property = LENGTH
Units:
cm, 0..10 - Limit decimal places = 1 |
 Number of finger tips admitted |
Number of finger tips that are able to be admitted into the internal or external os | Count
| optional
0..1 |
|
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
| Findings |
Findings about the cervical os | Text
| optional
0..1 |
Free or coded text |
|
|
|
|
|
|
| Vaginal fluid, Vaginal loss or discharge. Cluster (0..1) optional |
| |
Slot |
Type |
Occurrences |
Constraints |
|
CLUSTER |
0..* |
Include entries
|
|
|
|
| Detail, More focused examination findings. Cluster (0..1) optional |
| |
Slot |
Type |
Occurrences |
Constraints |
|
CLUSTER |
0..* |
Include entries
|
|
|
|
Slot |
Type |
Occurrences |
Constraints |
|
CLUSTER |
0..* |
Include entries
Exclude entries:
|
|
|
|
Concept |
Description |
Type |
Cardinality |
Values |
 Image |
Drawing or image of the area examined | MultiMedia
| optional, repeating
0..* |
image/gif
image/png
image/jpeg |
|
