Procedure archetype for operative notes

Wulff.Antje at mh-hannover.de Wulff.Antje at mh-hannover.de
Thu Feb 4 05:26:55 EST 2016


Hi everyone,

We're trying to model an operative note document - therefore we used the procedure archetype openEHR-EHR-ACTION.procedure.v1 and specialised it by adding other archetypes into the procedure details slot. Within the description of the procedure archetype it says
'Additional structured and detailed information about the procedure can be captured using purpose-specific archetypes inserted into the 'Procedure detail' slot'
but
'this archetype will be used to record only what was done during the procedure. Separate archetypes will be used to record the other required components of the Operation Report'.
I am a bit confused - we added something like specimens taken, devices, medication during surgery. Do you think it is valid to add these archetypes into the slot procedure details?
And what about elements like preoperative diagnosis, risks and anesthesia? I think these are detailed information for the surgery but they do not belong to the surgery itself - so they shouldn't be added.
What do you think?


Thanks for your help and ideas.


Kind regards
Antje

Antje Wulff

Peter L. Reichertz Institut für Medizinische Informatik
Technische Universität Braunschweig und
Medizinische Hochschule Hannover
Mühlenpfordtstraße 23
D-38106 Braunschweig

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