Procedure archetype for operative notes

Ian McNicoll ian at freshehr.com
Thu Feb 4 08:43:49 EST 2016


Hi Jakob

Can you point us to the WHO checklists you had in mind ? It is worth noting
that checklists are often orthogonal to operational data capture.

I would be thinking in terms of operative note as a composition , using the
procedure archetype with device and detailed method in the slot.

To maximise reuse I would probably put specimen inside the relevant lab
request archetype and similarly record meds using a medication order
archetype. Prepping diagnosis would use the problem-diagnosis archetype.

Is it worth working this up as an exemplar template to put up on CKM?

Ian
On Thu, 4 Feb 2016 at 11:47, Jakob Mathiszig-Lee <jakob at mathisziglee.co.uk>
wrote:

> 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" <
> 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 für Medizinische Informatik
>
> Technische Universität Braunschweig und
>
> Medizinische Hochschule Hannover
>
> Mühlenpfordtstraße 23
>
> D-38106 Braunschweig
>
>
>
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