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, "[email protected]<mailto:[email protected]>" <[email protected]<mailto:[email protected]>> 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 _______________________________________________ openEHR-clinical mailing list [email protected]<mailto:[email protected]> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
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