hi Ian (and others) I spent some time today working on the imaging exam archetype with Heather. We had some questions about the Finding Details section, and Heather thought that you are responsible for this part. And that part certainly leaves me confused.
There is a part called Detailed findings. In it, there is Finding name: Text The name of the finding e.g Chest, heart or bones for a Chest x-ray. Finding: Text Brief description, often coded, of an individual finding from an imaging procedure e.g. '2cm node in left upper lobe'. Finding description: Text A narrative, detailed description of each individual finding (note for other readers, this version of the archetype is in preparation, and isn't posted to the CKM) I don't know what the intent is here. Howe do you differentiate between these, and know how to use them consistently? In fact, I wasn't exactly sure what "detailed findings" is exactly meant to be - the term isn't really defined. I assumed it was for some structured representation of the contents of the narrative, presumably to support some kind of synoptic reporting? I'd add at least a Finding Value : ANY so that proper synoptic reports would be possible. Heather and I thought that some examples might help have a productive discussion. This is some of the things I thought might be useful to say in a coded way using snomed + values LMP: [value in months] size of (uterus, placenta, foetus): [value in mm] [Snomed Concept 84138006: Collapse of vertebra] 246120007: Nodule size = [20mm] 422005008: Ferucarbotran (product) That'll probably do to start us off. If no one claims reponsibility or defends this model, I'll suggest that we have just code | value following the classic HL7 model. It's certainly got it's problems, but at least they are well understood, and the openEHR model would match the HL7 v2/v3 models of the same Grahame p.s. I tried to code exactly "2cm node in left upper lobe", but snomed isn't vague in those ways
