TEMPLATE EAR Primary Hip Arthroplasty Report (EAR Primary Hip Arthroplasty Report)

TEMPLATE IDEAR Primary Hip Arthroplasty Report
ConceptEAR Primary Hip Arthroplasty Report
DescriptionTo capture Primary Hip Arthroplasty details consistent with the European Arthroplasty Register (EAR).
PurposeTo capture Primary Hip Arthroplasty details consistent with the European Arthroplasty Register (EAR).
References
Other Details (Language Independent)
  • MetaDataSet:Sample Set : Template metadata sample set
Language useden
Citeable Identifier1013.26.16
Root archetype idopenEHR-EHR-COMPOSITION.report.v1
EAR Primary Hip Arthroplasty ReportEAR Primary Hip Arthroplasty Report: Document to communicate information to others, commonly in response to a request from another party.
Other Context
PatientPatient: Identifiable details of a person compliant with European ISA standard.
Person IdentifierPerson Identifier: A unique personal identifier.
Person name (ISA)Person name (ISA): Personal name compliant with European ISA standard.
Family NameFamily Name: A family name is usually shared by members of a family. This attribute also carries prefixes or suffixes which are part of the Family Name, e.g. “de Boer”, “van de Putte”, “von und zu Orlow”.
Multiple family names, such as are commonly found in Hispanic countries, are recorded in the single Family Name field so that, for example, Miguel de Cervantes Saavedra's Family Name would be recorded as "de Cervantes Saavedra.
Given NameGiven Name: A given name, or multiple given names, are the denominator(s) that identify an individual within a family. These are given to a person by his or her parents at birth or may be legally recognised as 'given names' through a formal process.
All given names are ordered in one field so that, for example, the Given Name for Johan Sebastian Bach is 'Johan Sebastian.'
Date of BirthDate of Birth: The person's date of birth.
Anonymised person (PARENT)Anonymised person (PARENT): Anonymised details of a person.
Administrative GenderAdministrative Gender: Ther current administrative gender of the person.
  • Male 
  • Female 
  • Undetermined 
AgeAge: The age of the person. This may be calculated.
>PT0H
Units:
  • Year
  • Month
Reporting professionalReporting professional: Details of a healthcare professional.
Person name (ISA)Person name (ISA): Personal name compliant with European ISA standard.
Full NameFull Name: The full name (fullName) property contains the complete name of a person as one string. In addition to the content of given name, family name and, in some systems, patronymic name, this can carry additional parts of a person’s name such as titles, middle names or suffixes like “the third” or names which are neither a given nor a family name.
Professional IdentifierProfessional Identifier: The healthcare worker's profesional identifier.
Healthcare provider (PARENT)Healthcare provider (PARENT): Details of a healthcare provider organisation.
Department nameDepartment name: The name of the organisation.
Hospital identifierHospital identifier: The unique identifier of the organisation.
Address (ISA)Address (ISA): Address details compliant with European ISA Standard.
Post Name (city)Post Name (city): The key postal division of the address, usually the city.
Admin Unit 2 (county/region/state)Admin Unit 2 (county/region/state): The region of the address, usually a county, state or other such area that typically encompasses several localities.
Admin Unit 1 (country)Admin Unit 1 (country): The uppermost administrative unit for the address, almost always a country.
Department nameDepartment name: The name of a specific department within the organisation.
Department identifierDepartment identifier: The identifier of a specific department.
Contact detailsContact details: Contact details for the organisation.
Contact detailsContact details: Contact details for the heathcare worker.
Previous proceduresPrevious procedures: A generic section header which should be renamed in a template to suit a specific clinical context.
Procedure undertakenProcedure undertaken: A clinical activity that has been carried out for therapeutic or diagnostic purposes.
Description
Previous ProcedurePrevious Procedure: The name of the procedure.
  • Osteosynthesis
  • Femur
  • Acetabulum
  • Arthrodesis
  • [...]
Protocol
Healthcare provider (PARENT)Healthcare provider (PARENT): Details of a healthcare provider organisation.
Department nameDepartment name: The name of the organisation.
Hospital identifierHospital identifier: The unique identifier of the organisation.
Address (ISA)Address (ISA): Address details compliant with European ISA Standard.
Post Name (city)Post Name (city): The key postal division of the address, usually the city.
Admin Unit 2 (county/region/state)Admin Unit 2 (county/region/state): The region of the address, usually a county, state or other such area that typically encompasses several localities.
Admin Unit 1 (country)Admin Unit 1 (country): The uppermost administrative unit for the address, almost always a country.
Department nameDepartment name: The name of a specific department within the organisation.
Department identifierDepartment identifier: The identifier of a specific department.
Contact detailsContact details: Contact details for the organisation.
Exclusion of a ProcedureExclusion of a Procedure: Positive statement/s about procedures that need to be recorded as clinically excluded from the health record at a specific point in time.
Exclusion StatementExclusion Statement: A statement about exclusion of procedures performed in the health record.
For example: "No known operations or significant procedures" or "No previous" (appendicectomy).
  • No significant previous procedures
Default value: No significant previous procedures
Current procedureCurrent procedure: A generic section header which should be renamed in a template to suit a specific clinical context.
Procedure undertakenProcedure undertaken: A clinical activity that has been carried out for therapeutic or diagnostic purposes.
Current ProcedureCurrent Procedure: The name of the procedure.
  • Total hip replacement
  • Bipolar hip replacement
  • Partial hip replacement
  • [...]
Reason/s for procedureReason/s for procedure: The reason or indication for the procedure.
  • Primary Osteoarthritis
  • Dysplasia
  • Post-Traumatic
  • Aseptic Necrosis of Femoral Head
  • Post epipholysis / post Perthes
  • Rheumatoid Arthritis
  • [...]
Hip joint implantHip joint implant: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device nameDevice name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. With specific examples. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.
Default value: SNOMEDCT::303533002::Hip joint implant
Hip implant detailsHip implant details: Additional details of hip arthropasty component.
Cement nameCement name: The name of the cement used.
Fixation typeFixation type: The type of fixation used.
  • Cemented 
  • Non-cemented 
Fixation sub-typeFixation sub-type: The fixation sub-type.
Tesla levelTesla level: The tested MRI Tesla safety level.
0..5
Potential safety issuePotential safety issue: Issues identified or excluded that may have a safety impact e.g MRI risk.
Manufacturer safety informationManufacturer safety information: Link to manufacturer safety information.
Antibacterial in cement?Antibacterial in cement?: True if antibiotics/antibacterials were added to the cement.
Acetabular componentAcetabular component: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device nameDevice name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. With specific examples. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.
Default value: Acetabular component
TypeType: The category or kind of device.
Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers.
Acetabular detailsAcetabular details: Additional details of hip arthropasty component.
Cement nameCement name: The name of the cement used.
HA-CoatingHA-Coating: The name of the coating used.
Fixation typeFixation type: The type of fixation used.
  • Cemented 
  • Non-cemented 
Fixation sub-typeFixation sub-type: The fixation sub-type.
Tesla levelTesla level: The tested MRI Tesla safety level.
0..5
Potential safety issuePotential safety issue: Issues identified or excluded that may have a safety impact e.g MRI risk.
Manufacturer safety informationManufacturer safety information: Link to manufacturer safety information.
Antibacterial in cement?Antibacterial in cement?: True if antibiotics/antibacterials were added to the cement.
Batch/Lot numberBatch/Lot number: The number assigned by the manufacturer which identifies a group of items manufactured at the same time, usually found on the label or packaging material.
Femoral componentFemoral component: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device nameDevice name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. With specific examples. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.
Default value: Femoral component
TypeType: The category or kind of device.
Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers.
Hip arthroplasty componentHip arthroplasty component: Additional details of hip arthropasty component.
Cement nameCement name: The name of the cement used.
HA-CoatingHA-Coating: The name of the coating used.
Fixation typeFixation type: The type of fixation used.
  • Cemented 
  • Non-cemented 
Fixation sub-typeFixation sub-type: The fixation sub-type.
Tesla levelTesla level: The tested MRI Tesla safety level.
0..5
Potential safety issuePotential safety issue: Issues identified or excluded that may have a safety impact e.g MRI risk.
Manufacturer safety informationManufacturer safety information: Link to manufacturer safety information.
Batch/Lot numberBatch/Lot number: The number assigned by the manufacturer which identifies a group of items manufactured at the same time, usually found on the label or packaging material.
InlayInlay: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device nameDevice name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. With specific examples. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.
Default value: Acetabular inlay
TypeType: The category or kind of device.
Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers.
Batch/Lot numberBatch/Lot number: The number assigned by the manufacturer which identifies a group of items manufactured at the same time, usually found on the label or packaging material.
Head componentHead component: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
Device nameDevice name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. With specific examples. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.
Default value: Head component
TypeType: The category or kind of device.
Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers.
Batch/Lot numberBatch/Lot number: The number assigned by the manufacturer which identifies a group of items manufactured at the same time, usually found on the label or packaging material.
Specific locationSpecific location: Specific and identified anatomical location.
Name of locationName of location: Named anatomical location - ideally would be coded where possible.
Default value: Hip
SideSide: Specify lateraility of the anatomical location.
  • Left 
  • Right 
Healthcare provider (PARENT)Healthcare provider (PARENT): Details of a healthcare provider organisation.
Department nameDepartment name: The name of the organisation.
Hospital identifierHospital identifier: The unique identifier of the organisation.
Address (ISA)Address (ISA): Address details compliant with European ISA Standard.
Post Name (city)Post Name (city): The key postal division of the address, usually the city.
Admin Unit 2 (county/region/state)Admin Unit 2 (county/region/state): The region of the address, usually a county, state or other such area that typically encompasses several localities.
Admin Unit 1 (country)Admin Unit 1 (country): The uppermost administrative unit for the address, almost always a country.
Department nameDepartment name: The name of a specific department within the organisation.
Department identifierDepartment identifier: The identifier of a specific department.
Contact detailsContact details: Contact details for the organisation.