Procedure archetype for operative notes

Jakob Mathiszig-Lee jakob at mathisziglee.co.uk
Thu Feb 4 08:50:40 EST 2016


It's the WHO safe surgery check list: 
http://www.who.int/patientsafety/safesurgery/checklist/en/
The completed version (printed if electronically) gets filed as part of 
the operative record in the theaters i've worked in

> Ian McNicoll <mailto:ian at freshehr.com>
> 04 February 2016 13:43
> 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
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> Jakob Mathiszig-Lee <mailto:jakob at mathisziglee.co.uk>
> 04 February 2016 10:47
> 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 für Medizinische Informatik
>>
>> Technische Universität Braunschweig und
>>
>> Medizinische Hochschule Hannover
>>
>> Mühlenpfordtstraße 23
>>
>> D-38106 Braunschweig
>>
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>> openEHR-clinical mailing list
>> openEHR-clinical at lists.openehr.org 
>> <mailto:openEHR-clinical at lists.openehr.org>
>> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
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> Wulff.Antje at mh-hannover.de <mailto:Wulff.Antje at mh-hannover.de>
> 04 February 2016 10:26
>
> 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
>
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical at lists.openehr.org
> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org

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