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 <[email protected]> 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, "[email protected]" < > [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 für Medizinische Informatik > > Technische Universität Braunschweig und > > Medizinische Hochschule Hannover > > Mühlenpfordtstraße 23 > > D-38106 Braunschweig > > > > _______________________________________________ > openEHR-clinical mailing list > [email protected] > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org > > _______________________________________________ > openEHR-clinical mailing list > [email protected] > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
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