Procedure archetype for operative notes

Ian McNicoll ian at freshehr.com
Mon Feb 15 12:06:48 EST 2016


Hi Birger,

Sorry for the delay in responding.

I suspect this is one of the situations where it feels like you have found
a consistentpattern i.e. 'surgical times' but where each procedure and
speciality may have very different ideas about exactly which times are
significant. I had a similar experience when modelling metastatic cancer
spread, where there initially seems to be a lot of commonality but you
quickly get into a tangle with exceptions and redundant elements.

My inclination would be to create a generic cluster for operative details,
including the common 'surgical times' but expect to have to 'fork' this
frequently in the way that the physical examination archetypes are now
modelled - i.e aim for generic patterns, rathe than true inheritance.

I don't think these sub-events really qualify as Care steps.  The only
exception might be pre-op and post-op procedures/summary which perhaps
merit their own archetypes but for now I would probably just include these
within the operative details CLUSTER archetype.

Ian

Dr Ian McNicoll
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Co-Chair, openEHR Foundation ian.mcnicoll at openehr.org
Director, freshEHR Clinical Informatics Ltd.
Director, HANDIHealth CIC
Hon. Senior Research Associate, CHIME, UCL

On 9 February 2016 at 12:15, <Wulff.Antje at mh-hannover.de> wrote:

> Hi everyone,
>
> Thanks for sharing your ideas on modelling an operative report. I decided
> to use the procedure archetype in the way Ian described.  Now I am thinking
> about how to integrate the different surgery steps, e.g. pre-operative
> preparation of the room/of the patient, incision to closure, post-operative
> preparation... for each step there is a specific date/time which has to be
> represented within  an archetype. Do you think it might be possible to use
> the PATHWAY  within the ACTION archetypes?
>
> The first idea was to create a CLUSTER archetype called 'surgical times'
> in which each surgery step is represented by one data element (by using the
> data type date/time) but it does not feel very comfortable to me.
>
> Thanks for your help
>
> Regards,
>
> Antje
>
>
>
> Birger Haarbrandt
>
> Hi all,
>
> I think it would be a good idea to have an example template. It might
> serve as a good starting point and reference model (not to be confused with
> the openEHR Reference Model :). However, our current effort is to create a
> template that mimics two surgery management systems at Hannover Medical
> School for the purpose of data integration. Therefore, the results might
> need some additional editing to become a good and generic example.
>
> Cheers,
>
> Birger
>
> Jakob Mathiszig-Lee <jakob at mathisziglee.co.uk> hat am 4. Februar 2016 um
> 14:50 geschrieben:
>
> 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* <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
>
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical at lists.openehr.org
>
> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
>
> *Jakob Mathiszig-Lee* <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" <
> 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 at lists.openehr.org
>
> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
>
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>
> openEHR-clinical mailing list
>
> openEHR-clinical at lists.openehr.org
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>
> *Wulff.Antje at mh-hannover.de* <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
>
>
>
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> openEHR-clinical at lists.openehr.org
>
> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
>
>
>
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>
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>
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