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Procedure (EHR Archetype) - openEHR-EHR-ACTION.procedure.v1

- 2017-07-08 - 1 Formulär, 1 Item-grupp, 24 Dataelement, 7 Språk
Item-grupp: openEHR-EHR-ACTION.procedure.v1.xml
Derived from www.openehr.org . Use to record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion. This is done by the recording of data against specific activities, as defined by the 'Pathway' careflow steps in this archetype. The scope of this archetype encompasses activities for a broad range of clinical procedures performed for evaluative, investigative, screening, diagnostic, curative, therapeutic or palliative purposes. Examples range from the relatively simple activities, such as insertion of an intravenous cannula, through to complex surgical operations. Additional structured and detailed information about the procedure can be captured using purpose-specific archetypes inserted into the 'Procedure detail' slot, where required. Timings related to a procedure can be managed in one of two ways: - Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step. - Archetyped data elements: --- the 'Scheduled date/time' data element is intended to record the precise time when the procedure is planned. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the procedure was scheduled into a system, not the intended date/time on which the procedure is intended to be carried out; and --- the 'Final end date/time' is intended to record the precise time when the procedure was ended. It can be used to document the complex procedures with multiple components. Note: the corresponding ACTION time attribute for the 'Procedure performed' will document the time each component performed was commenced. This 'Final end date/time' data element will record the date/time of the final active component of the procedure. This will enable a full duration of the active procedure to be calculated. Within the context of an Operation Report, 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, including the taking of tissue specimen samples, use of imaging guidance, operation findings, post-operative instructions and plans for follow up. Within the context of a Problem list or summary, this archetype may be used to represent procedures that have been performed. The EVALUATION.problem_diagnosis will be used to represent the patient's problems and diagnoses. In practice, many procedures (for example, in ambulatory care) will occur once and not be ordered in advance. The details about the procedure will be added against the pathway step, 'Procedure completed'. In some cases a recurring procedure will be ordered, and in this situation data against the 'Procedure performed' step will be recorded on each occasion, leaving the instruction in the active state. When the last occurrence is recorded the 'Procedure completed' action is recorded showing that this order is now in the completed state. In other situations, such as secondary care, there may be a formal order for a procedure using a corresponding INSTRUCTION archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out. Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will usually be the procedure itself but may be a failed attempt or another activity such as postponing the procedure. If there is a formal order for the procedure, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a Gastroscopy order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step: - record the scheduled Start date/time for the gastroscopy (Procedure scheduled); and - record that the gastroscopy procedure has been completed, including information about the procedure details (Procedure completed). Please note that in the openEHR Reference Model there is a 'Time' attribute, which is intended to record the date and time at which each pathway step of the Action was performed. This is the attribute to use to record the start of the procedure (using the 'Procedure performed' pathway step) or the time that the procedure was aborted (using the 'Procedure aborted' pathway step).

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