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:[email protected]>
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:[email protected]>
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, "[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 für Medizinische Informatik
Technische Universität Braunschweig und
Medizinische Hochschule Hannover
Mühlenpfordtstraße 23
D-38106 Braunschweig
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[email protected] <mailto:[email protected]>
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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