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

ARCHETYPE IDopenEHR-EHR-ACTION.procedure.v1
ConceptProcedure
DescriptionA clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes.
UseUse 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).
MisuseNot to be used to record details about the anaesthetic - use a separate ACTION archetype for this purpose. Not to be used to record details about imaging investigations - use ACTION.imaging_exam for this purpose. Not to be used to record details about laboratory investigations - use ACTION.laboratory_test for this purpose. Not to be used to record details about education delivered - use ACTION.health_education for this purpose. Not to be used to record details about administrative activities - use specific ADMIN archetypes for this purpose. Not to be used to record details about related activities such as the use of frozen sections taken during an operation, medication administered as part of the procedure or when imaging guidance is used during the procedure - use separate and specific ACTION archetypes within the same template for this purpose . Not to be used to record a whole operation or procedure report - use a template in which this archetype is only one component of the full report.
PurposeTo record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion.
ReferencesProcedure, Draft Archetype [Internet]. National eHealth Transition Authority, Australia, NEHTA Clinical Knowledge Manager [cited: 2015-03-21]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.936.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Ocean Informatics, Australia
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-03-12
Other Details LanguageAuthor name: Heather Leslie
Organisation: Ocean Informatics, Australia
Email: heather.leslie@oceaninformatics.com
Date originally authored: 2007-03-12
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Procedure, Draft Archetype [Internet]. National eHealth Transition Authority, Australia, NEHTA Clinical Knowledge Manager [cited: 2015-03-21]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.936., current_contact=Heather Leslie, Ocean Informatics, heather.leslie@oceaninformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=CCA98FC01E850D302CF1E149938C4E54, build_uid=5513cbfe-87bb-4539-a3b1-f504f30de2e8, revision=1.3.2}
Keywordsprocedure, intervention, surgical, medical, clinical, therapeutic, diagnostic, cure, treatment, evaluation, investigation, screening, palliative, therapy
Lifecyclepublished
UID82e79f18-76b9-4b5c-a930-1115eecbc4b7
Language useden
Citeable Identifier1246.145.621
Revision Number1.3.2
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes., archetypeConceptComment=null, otherContributors=Morten Aas, Oslo Universitetssykehus, Norway
Tomas Alme, DIPS, Norway
Vebjørn Arntzen, Oslo University Hospital, Norway
Koray Atalag, University of Auckland, New Zealand
Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor)
Kari Beate Engseth, Finnmarkssykehuset HF + Klinikk Kirkenes, Norway
Maria Beate Nupen, Oslo Universitetssykehus, Norway
Lars Bitsch-Larsen, Haukeland University hospital, Norway
Fredrik Borchsenius, Oslo universitetssykehus, Norway
Diego Bosca, IBIME group, Spain
Rong Chen, Cambio Healthcare Systems, Sweden
Stephen Chu, NEHTA, Australia (Editor)
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
David Evans, Queensland Health, Australia
Shahla Foozonkhah, Iran ministry of health and education, Iran
Einar Fosse, National 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
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 Ivar Mehlum, Helse Bergen HF, Norway
Lars Karlsen, DIPS ASA, Norway
Lars Morgan Karlsen, DIPS ASA, Norway
Mary Kelaher, NEHTA, Australia
Shinji Kobayashi, Kyoto University, Japan
Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway
Heather Leslie, Ocean Health Systems, Australia (openEHR Editor)
Hugh Leslie, Ocean Informatics, Australia
Hallvard Lærum, Oslo University Hospital, Norway
Mike Martyn, The Hobart Anaesthetic Group, Australia
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Bjoern Naess, DIPS ASA, Norway
Bjørn Næss, DIPS ASA, Norway
Andrej Orel, Marand d.o.o., Slovenia
Michael Osborne, Mater Health Services, Australia
Anne Pauline Anderssen, Helse Nord RHF, Norway
Chris Pearce, Melbourne East GP Network, Australia
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Jussara Rotzsch, UNB, Brazil
Peter Scott, Australia
Elizabeth Stanick, Hobart Anaesthetic Group, Australia
Norwegian Review Summary, Nasjonal IKT HF, Norway
Line Sørensen, Helse Bergen, Norway
John Taylor, NEHTA, Australia
Micaela Thierley, Helse Bergen, Norway
Rowan Thomas, St. Vincent's Hospital Melbourne, Australia
Line Thomassen, Helse Bergen, Norway
John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør)
Richard Townley-O'Neill, NEHTA, Australia
Ørjan Vermeer, Haukeland Universitetssjukehus, Kvinneklinikken, Norway
Ivar Yrke, DIPS AS, Norway, originalLanguage=en, translators=German: Kim Sommer, MHH, sommer.kimkatrin@mh-hannover.de
Russian: Art Latyp; Латыпов Артур, RusBITech; РусБИТех, Москва, hmm
Norwegian Bokmål: John Tore Valand / Silje Ljosland Bakke, Helse Bergen HF / Nasjonal IKT HF
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, CaboLabs, pablo.pazos@cabolabs.com, Computer Engineer, Pablo.Pazos@Cabolabs.Com: pablo.pazos@cabolabs.com
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itemType=ELEMENT, level=2, text=Description, description=Narrative description about the procedure, as appropriate for the pathway step., comment=For example: description about the performance and findings from the the procedure, the aborted attempt or the cancellation of the procedure., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0065], code=at0065, itemType=ELEMENT, level=2, text=Method, description=Identification of specific method or technique for the procedure., comment=Use this data element to record simple terms or a narrative description. 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If the method is included in the 'Procedure name' via precoordinated codes, this data element becomes redundant., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0058], code=at0058, itemType=ELEMENT, level=2, text=Urgency, description=Urgency of the procedure., comment=Coding with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0063], code=at0063, itemType=ELEMENT, level=2, text=Body site, description=Identification of the body site for the procedure., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0003], code=at0003, itemType=SLOT, level=2, text=Procedure detail, description=Structured information about the procedure., comment=Use to capture detailed, structured information about anatomical location, method & technique, equipment used, devices implanted, results, findings etc., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.device.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location.v1 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_clock.v0 and specialisations Or
openEHR-EHR-CLUSTER.anatomical_location_relative.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0048], code=at0048, itemType=ELEMENT, level=2, text=Outcome, description=Outcome of procedure performed., comment=Coding with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0069], code=at0069, itemType=ELEMENT, level=2, text=Procedural difficulty, description=Difficulties or issues encountered during performance of the procedure., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0006], code=at0006, itemType=ELEMENT, level=2, text=Complication, description=Details about any complication arising from the procedure., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0066], code=at0066, itemType=ELEMENT, level=2, text=Scheduled date/time, description=The date and/or time on which the procedure is intended to be performed., comment=Only for use in association with the 'Procedure scheduled' pathway step., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0060], code=at0060, itemType=ELEMENT, level=2, text=Final end date/time, description=The date and/or time when the entire procedure, or the last component of a multicomponent procedure, was finished., comment=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., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0061], code=at0061, itemType=ELEMENT, level=2, text=Total duration, description=The total amount of time taken to complete the procedure, which may include time spent during the active phase of the procedure plus time during which the procedure was suspended., comment=Only for use in association with the 'Procedure completed' pathway steps., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DURATION, bindings=null, values=>=0 seconds
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0062], code=at0062, itemType=SLOT, level=2, text=Multimedia, description=Mulitimedia representation of a performed procedure., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0067], code=at0067, itemType=ELEMENT, level=2, text=Procedure type, description=The type of procedure., comment=This pragmatic data element may be used to support organisation within the user interface., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0014], code=at0014, itemType=ELEMENT, level=2, text=Reason, description=Reason that the activity or care pathway step for the identified procedure was carried out., comment=For example: the reason for the cancellation or suspension of the procedure., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/description[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the activity or care pathway step not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], source=[]}, topLevelItems={description=ResourceSimplifiedHierarchyItem [path=ROOT_/description[at0001], code=at0001, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=1..*, subCardinalityText=, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0053], code=at0053, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], ism_transition=ResourceSimplifiedHierarchyItem [path=ROOT_/ism_transition[at0004], code=at0004, itemType=ISM_TRANSITION, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=1..1, cardinalityText=mandatory, subCardinalityFormal=null, subCardinalityText=null, dataType=ISM_TRANSITION, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0053]/items[at0054], code=at0054, itemType=ELEMENT, level=2, text=Requestor order identifier, description=The local ID assigned to the order by the healthcare provider or organisation requesting the service., comment=This is equivalent to Placer Order Number in HL7 v2 specifications., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
  •  Identifier
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0053]/items[at0055], code=at0055, itemType=SLOT, level=2, text=Requestor, description=Details about the healthcare provider or organisation requesting the service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0053]/items[at0056], code=at0056, itemType=ELEMENT, level=2, text=Receiver order identifier, description=The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier., comment=This is equivalent to Filler Order Number in HL7 v2 specifications., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
  •  Text
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, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0053]/items[at0057], code=at0057, itemType=SLOT, level=2, text=Receiver, description=Details about the healthcare provider or organisation receiving the request for service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0053]/items[at0064], code=at0064, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]