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).
Organisation: Ocean Informatics, Australia
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-03-12
Organisation: Ocean Informatics, Australia
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-03-12
- Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
- Custodian Organisation: openEHR Foundation
- Current Contact: Heather Leslie, Atomica Informatics, heather.leslie@atomicainformatics.com
- Original Namespace: org.openehr
- Original Publisher: openEHR Foundation
- Custodian Namespace: org.openehr
- MD5-CAM-1.0.1: 03F9461E34A327AE0A6B413BEAAC0A13
- Build Uid: bb041202-d1bc-4bf9-b531-20e72ed8ff30
- Revision: 1.4.9
Current state: planned
Current state: initial
Current state: planned
Current state: initial
Current state: postponed
Current state: cancelled
Current state: scheduled
Current state: active
Current state: active
Current state: suspended
Current state: aborted
Current state: completed
Coding of the specific procedure with a terminology is preferred, where possible.
For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure.
Coding of the indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Failed bowel preparation' or 'Bowel cancer screening'.
Use this data element to record simple terms or a narrative description. If the requirements for recording the method require more complex modelling then this can be represented by additional archetypes within the 'Procedure detail' SLOT in this archetype. If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
Coding with a terminology is preferred, where possible.
Occurrences for this data element are unbounded to allow for clinical scenarios such as removing multiple skin lesions in different places, but where all of the other attributes are identical. Use this data element to record simple terms or precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Procedure detail' SLOT in this archetype. If the anatomical location is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant.
Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc.
Include:
openEHR-EHR-CLUSTER.device.v1 and specialisations or
openEHR-EHR-CLUSTER.anatomical_
openEHR-EHR-CLUSTER.anatomical_
openEHR-EHR-CLUSTER.anatomical_
Coding with a terminology is preferred, where possible.
Examples: The patient was agitated, insufficient emptying of the stomach before gastroscopy, a tumour in the bile ducts made it impossible to pass the scope through.
Use this data element to record simple terms or precoordinated complications. If the requirements for recording complication are more complex then use of a specific CLUSTER archetype within the 'Procedure detail' SLOT in this archetype is advised and this data element becomes redundant. Examples: Hematuria after a kidney biopsy, tissue irritation after insertion of intravenous catheter.
Only for use in association with the 'Procedure scheduled' pathway step.
Only for use in association with the 'Procedure performed' pathway step, and in situations where the procedure is repeated on multiple occasions before being completed or there are multiple components to the whole procedure. This may be the same as the RM time attribute for the 'Procedure completed' pathway step.
Only for use in association with the 'Procedure completed' pathway steps.
>=0 seconds
Include:
openEHR-EHR-CLUSTER.media_
This pragmatic data element may be used to support organisation within the user interface.
For example: the reason for the cancellation or suspension of the procedure.
This is equivalent to Placer Order Number in HL7 v2 specifications.
Choice of:
Text
Identifier
Include:
All not explicitly excluded archetypes
This is equivalent to Filler Order Number in HL7 v2 specifications.
Choice of:
- Text
- Identifier
Include:
All not explicitly excluded archetypes
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Include:
All not explicitly excluded archetypes
Tomas Alme, DIPS, Norway
Anne Pauline Anderssen, Helse Nord RHF, Norway
Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Helse Vest IKT AS, Norway (Nasjonal IKT redaktør)
Maria Beate Nupen, Oslo Universitetssykehus, Norway
Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway
Fredrik Borchsenius, Oslo universitetssykehus, Norway
Diego Bosca, VeraTech for Health, Spain
Hanne Marte Bårholm, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, NEHTA, Australia (Editor)
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Kari Beate Engseth, Finnmarkssykehuset HF + Klinikk Kirkenes, Norway
David Evans, Queensland Health, Australia
Shahla Foozonkhah, Iran ministry of health and education, Iran
Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway
Sebastian Garde, Ocean Informatics, Germany
Jacquie Garton-Smith, Royal Perth Hospital and DoHWA, Australia
Bente Gjelsvik, Helse Bergen, Norway
Andrew Goodchild, NEHTA, Australia
Heather Grain, Llewelyn Grain Informatics, Australia
Mikkel Johan Gaup Grønmo, Helse Nord IKT, Norway (Nasjonal IKT redaktør)
Megan Hawkins, Mater Health Services, Australia
Sam Heard, Ocean Informatics, Australia
Kristian Heldal, Telemark Hospital Trust, Norway
Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway
Anca Heyd, DIPS ASA, Norway
Hilde Hollås, DIPS ASA, Norway
Lars Morgan Karlsen, Nordlandssykehuset Bodø, Norway
Mary Kelaher, NEHTA, Australia
Shinji Kobayashi, Kyoto University, Japan
Kanika Kuwelker, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Liv Laugen, Oslo universitetssykehus, Norway (Nasjonal IKT redaktør)
Sabine Leh, Helse Bergen, Norway
Heather Leslie, Atomica Informatics, Australia
Hugh Leslie, Ocean Informatics, Australia
Hallvard Lærum, Direktoratet for e-helse, Norway
Mike Martyn, The Hobart Anaesthetic Group, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Lars Ivar Mehlum, Nasjonal IKT HF, Norway
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Maria Beate Nupen-Stieng, Oslo Universitetssykehus, Norway
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Michael Osborne, Mater Health Services, Australia
Chris Pearce, Melbourne East GP Network, Australia
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Norwegian Review Summary, Nasjonal IKT HF, Norway
Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil
Peter Scott, Australia
Elizabeth Stanick, Hobart Anaesthetic Group, Australia
Line Sørensen, Helse Bergen, Norway
John Taylor, NEHTA, Australia
Micaela Thierley, Helse Vest IKT, Norway
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Line Thomassen, Helse Bergen, Norway
Richard Townley-O'Neill, NEHTA, Australia
John Tore Valand, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Marit Alice Venheim, Helse Vest IKT, Norway (Nasjonal IKT redaktør)
Ørjan Vermeer, Haukeland Universitetssjukehus, Kvinneklinikken, Norway
Ivar Yrke, DIPS AS, Norway
- German: Kim Sommer, Natalia Strauch, MHH, Medizinische Hochschule Hannover, sommer.kimkatrin@mh-hannover.de, Strauch.Natalia@mh-hannover.de
- Portuguese (Portugal): Ana Garcia Niza, EY, ana.niza16@gmail.com, I have no accreditation
- Russian: Art Latyp; Латыпов Артур, RusBITech; РусБИТех, Москва, hmm
- Swedish: Sofia Lång Janstad, Romi Shweta Pathak, Anette Larsson, Åsa Skagerhult, Per Nemirovski, Anders Thurin, Jörgen Kuylenstierna, Emma Molin, Henrik Nilsson, Sajjad Saffari Miandoab, Mikael Nyström, SLL, Karolinska universitetssjukhuset, Tieto Sweden AB, openEHR Sverige, Region Östergötland, B3 HealthTech, Västra Götalandsregionen, Region Uppsala, Cambio, Eweave, CAG, sofia.lang-janstad@sll.se, romi.pathak@regionstockholm.se, anette.a.larsson@tietoevry.com, asa.skagerhult@regionostergotland.se, per.nemirovski@b3.se, sajjad.saffari-miandoab@regionstockholm.se, jorgen.kuylenstierna@solvikshalsan.se, emma.molin@cambio.se, anders.thurin@vgregion.se, Henrik.Nilsson@cag.se, Mikael.Nystrom@cambio.se
- Norwegian Bokmål: John Tore Valand / Silje Ljosland Bakke, Helse Bergen HF / Nasjonal IKT HF, john.tore.valand@helse-bergen.no
- Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês, osmeire.acsanzovo@hsl.org.br
- Arabic (Syria): Mona Saleh
- Slovenian: Uroš Rajkovič, Biljana Prinčič, Slovenia
- Spanish (Spain): Pablo Pazos, Julio de Sosa, CaboLabs, Servei Català de la Salut, pablo.pazos@cabolabs.com, juliodesosa@catsalut.cat, Computer Engineer, Pablo.Pazos@Cabolabs.Com: pablo.pazos@cabolabs.com
- Catalan: Julio de Sosa, Servei Català de la Salut, juliodesosa@catsalut.cat