Procedure archetype for operative notes

Jakob Mathiszig-Lee jakob at mathisziglee.co.uk
Thu Feb 4 05:47:08 EST 2016


Speaking as an anaesthetist there's enough going on on an anaesthetic chart to warrant its own archetype imo.

Specimens, sets used and local anaesthetic infiltrated by the surgeon are generally recorded in the op note section of an operative booklet. I suspect specimens don't have to be included if they'd be recorded by virtue of electronic requesting.

One other thing is to work out where the WHO checklists fits in around the op note


On 4 Feb 2016, at 10:28, "Wulff.Antje at mh-hannover.de<mailto:Wulff.Antje at mh-hannover.de>" <Wulff.Antje at mh-hannover.de<mailto:Wulff.Antje at mh-hannover.de>> wrote:

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 f?r Medizinische Informatik
Technische Universit?t Braunschweig und
Medizinische Hochschule Hannover
M?hlenpfordtstra?e 23
D-38106 Braunschweig

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