ARCHETYPE ID | openEHR-EHR-ACTION.procedure.v1 |
Concept | Procedure |
Description | A clinical activity carried out for screening, investigative, diagnostic, curative, therapeutic, evaluative or palliative purposes. |
Use | 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). |
Misuse | Not 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. |
Purpose | To record information about the activities required to carry out a procedure, including the planning, scheduling, performance, suspension, cancellation, documentation and completion. |
References | |
Copyright | © openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Ocean Informatics, Australia Email: heather.leslie@oceaninformatics.com Date originally authored: 2007-03-12 |
Other Details Language | Author 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 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=A83EF7B3123876997EA6F292C16A246D, build_uid=00c961dd-1ef5-40b5-84fd-b18486797494, revision=1.4.6} |
Keywords | procedure, intervention, surgical, medical, clinical, therapeutic, diagnostic, cure, treatment, evaluation, investigation, screening, palliative, therapy |
Lifecycle | published |
UID | 82e79f18-76b9-4b5c-a930-1115eecbc4b7 |
Language used | en |
Citeable Identifier | 1013.1.204 |
Revision Number | 1.4.6 |
All | Archetype [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, Diakonhjemmet Sykehus, Norway 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, originalLanguage=en, translators=
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