AW: Procedure archetype for operative notes

Wulff.Antje at mh-hannover.de Wulff.Antje at mh-hannover.de
Tue Feb 16 05:35:23 EST 2016


For a better discussion, I will try to put together my ideas for an operative report template and the corresponding archetypes into a mindmap as soon as possible! Thanks for the link, Ian.

Yes, Vebjørn – from my work I know that there often is a combination of manual input (the documentation starts during the surgery, especially the ‘live’ documentation of the surgical times) and medical devices (e.g. scanning of implants). On the other hand, some elements are added after the surgery.
I think we have to be clear about the term ‘operative note’ – often the surgeon dictates the procedure after the surgery but there is another type of an operative document (called operative report in English, I guess). The operative report summarizes details about devices used, materials, the team and their tasks, times…This documentation often starts during the surgery (done by nursing staff). So, as Ian said there are many different needs…


Antje Wulff

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

Ian McNicoll


Hi Vebjørn,

I totally agree in principle but sometimes implementers have to compromise and reflect the immediate needs of registry/reporting style recording. It is fine balance!!

I have setup the Incubator

If you are already registered for CKM, clicking on this link http://openehr.org/ckm/#signUp_1013.30.31_75c49a0ef23ac19717c94fcafd3377ee

will add you as a member/reviewer of the Incubator.

If you are not registered for CKM, the link will take you through the registration process  (it is all free!), then add you to the Incubator.

Anyone who wants to add resources - mindmaps, example documents, or archetypes/templates - contact me directly.

Ian


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On 16 February 2016 at 09:33, Vebjørn Arntzen <varntzen at ous-hf.no<mailto:varntzen at ous-hf.no>> wrote:
I'm not sure we would like to continue todays practice, when the surgeon is making the operative note after the operation is over. As a general rule, data should be captured as they are produced, to avoid the extra work afterwards. (And as we know, that gives us poorer data quality and delay). So a solution that captures data as the surgery is being performed, will be very welcomed! The source of this will be from manual input from personel attending the operation, maybe from medical devices or from a third-party system (such as a charting system) in a type of combination of them all. Therefore the archetypes should be constructed to handle this.

Vebjørn

PS: I didn't know attachments were not allowed here, my mistake. Incubator? Yes, please ☺

Fra: openEHR-clinical [mailto:openehr-clinical-bounces at lists.openehr.org<mailto:openehr-clinical-bounces at lists.openehr.org>] På vegne av Ian McNicoll
Sendt: 16. februar 2016 10:12
Til: For openEHR clinical discussions
Emne: Re: Procedure archetype for operative notes

Hi Anca, Antje

I also agree about recording anaesthesia separately, especially if the template is being used in an operational system.

The various sub-steps could be regarded as their own ACTION/ OBSERVATIONS etc but sometimes this just makes the modelling too complicated. If the documentation is an operative note made by a surgeon after the procedure, he/she is essentially making a summary report in hindsight, rather than documenting the steps as he/she goes along. Definitely an area to explore further.

@Vebjørn - good suggestion. It is difficult to discuss these areas without clear examples. For policy reasons, this list does not accept attachments (under discussion). We could setup an Incubator on the international CKM and upload resources there. If people want to email mindmaps etc directly, I am happy to upload them to CKM.

Ian


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On 16 February 2016 at 08:45, <Wulff.Antje at mh-hannover.de<mailto:Wulff.Antje at mh-hannover.de>> wrote:
Hi everyone,

Anca, I agree with you. I think it would be better to have an own procedure action archetype for anesthesia. There are some more of these actions which can be done during a surgery, e.g. X-Ray/imaging help, blood arrest, pre-operative examination – I think it is not valid to model these concepts as CLUSTER because these are own ACTIONS, right? Unfortunately, it is not possible to add these ‘special methods’-archetypes into the details-slot of the surgery procedure archetype then (e.g. within a template) – so you can’t really represent that these actions may be a part of the surgery action.
How would be the approach to represent something like sub-actions?


Antje Wulff

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

Anca Heyd

Hi everybody.

I get involved a little late in this discussion, sorry for this but I did not know obout this forum.

The point is, we have already worked a lot on surgery and how to model the whole process.

We have implemented planning of surgery already and we did it by modelling a template for decision for surgery.

Like you we used the procedure INSTRUCTION archetype and it seems to work well. There is only one difference.

We decided to have one procedure instruction for the surgery an d one for the anesthesia. This because you sometimes you need surgery without anesthesia or anesthesia without surgery and we think that these to are so different that I makes sense to describe them as own procedure.

Than we added a lot of Clusters with details like information about priority details, special needs for surgery, plan for anesthesia etc.

That was the planning.

We are now proceeding to performing and documenting the procedure and we actually also thought of using the action care steps for registration of the different times/states during an operation.

Ian could you tell a little bit more about why do you think this would not be a good idea?



Ha en strålende dag
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Anca
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Fra: openEHR-clinical [mailto:openehr-clinical-bounces at lists.openehr.org<mailto:openehr-clinical-bounces at lists.openehr.org>] På vegne av Ian McNicoll
Sendt: mandag 15. februar 2016 18.07
Til: For openEHR clinical discussions <openehr-clinical at lists.openehr.org<mailto:openehr-clinical at lists.openehr.org>>
Emne: Re: Procedure archetype for operative notes

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


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