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 mobile +44 (0)775 209 7859 office +44 (0)1536 414994 skype: ianmcnicoll email: [email protected] twitter: @ianmcnicoll Co-Chair, openEHR Foundation [email protected] Director, freshEHR Clinical Informatics Ltd. Director, HANDIHealth CIC Hon. Senior Research Associate, CHIME, UCL On 9 February 2016 at 12:15, <[email protected]> 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 <[email protected]> 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* <[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 > > _______________________________________________ > openEHR-clinical mailing list > [email protected] > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org > > *Jakob Mathiszig-Lee* <[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]" < > [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 > > *[email protected]* <[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 > > > > _______________________________________________ > openEHR-clinical mailing list > [email protected] > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org > > > > -- > > Sent from Postbox > <https://www.postbox-inc.com/?utm_source=email&utm_medium=siglink&utm_campaign=reach> > > > > > _______________________________________________ > 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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