TEMPLATE Slovenia RES Primary Hip Arthroplasty Report (Slovenia RES Primary Hip Arthroplasty Report)

TEMPLATE ID	Slovenia RES Primary Hip Arthroplasty Report
Concept	Slovenia RES Primary Hip Arthroplasty Report
Description	To capture Hip arthroplasty details consistent with the National Arthroplasty Registry of Slovenia (RES).
Purpose	To capture Hip arthroplasty details consistent with the National Arthroplasty Registry of Slovenia (RES).
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1013.26.33
Root archetype id	openEHR-EHR-COMPOSITION.report.v1
Slovenia RES Primary Hip Arthroplasty Report	Slovenia RES Primary Hip Arthroplasty Report: Document to communicate information to others, commonly in response to a request from another party.
Other Context
Patient	Patient: Identifiable details of a person compliant with European ISA standard.
Id-Code1	Id-Code1: A unique personal identifier.
KZZ	KZZ: A unique personal identifier.
EMŠO	EMŠO: A unique personal identifier.
Ehic Carrier Id	Ehic Carrier Id: A unique personal identifier.
Ehic_pin	Ehic_pin: A unique personal identifier.
Matični index	Matični index: A unique personal identifier.
Person name (ISA)	Person name (ISA): Personal name compliant with European ISA standard.
Family Name	Family 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 Name	Given 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 Birth	Date of Birth: The person's date of birth.
Anonymised person (PARENT)	Anonymised person (PARENT): Anonymised details of a person.
Gender	Gender: Ther current administrative gender of the person. Male Female Undetermined
Death details (PARENT)	Death details (PARENT): Details of person's death aligned with PARENT Common Data Elements for registry use.
Date of death	Date of death: The date of the subject's death.
Reporting professional	Reporting professional: Details of a healthcare professional.
Person name (ISA)	Person name (ISA): Personal name compliant with European ISA standard.
Full Name	Full 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 Identifier	Professional Identifier: The healthcare worker's profesional identifier.
Healthcare provider (PARENT)	Healthcare provider (PARENT): Details of a healthcare provider organisation.
Hospital name	Hospital name: The name of the organisation.
Hospital identifier	Hospital identifier: The unique identifier of the organisation.
Address (ISA)	Address (ISA): Address details compliant with European ISA Standard.
Thoroughfare (street name)	Thoroughfare (street name): An address component that represents the name of a passage or way through from one location to another. A thoroughfare is not necessarily a road, it might be a waterway or some other feature.
Locator Designator (street number)	Locator Designator (street number): this is the building number, apartment number, etc. For an address such as "Flat 3, 17 Bridge Street", the locator is "flat 3, 17."
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 name	Department name: The name of a specific department within the organisation.
Contact details	Contact details: Contact details for the heathcare worker.
Previous procedures	Previous procedures: A generic section header which should be renamed in a template to suit a specific clinical context.
Primary hip arthroplasty - previous procedure	Primary hip arthroplasty - previous procedure: Details of procedures prior to primary hip arthroplasty.
Previous procedure	Previous procedure: The name of the procedure. Coded Text Osteosynthesis after fracture Osteotomy of Femur Osteotomy of Acetabulum Arthrodesis Text
Anatomical Location	Anatomical Location: Record details about an anatomical location.
Specific location	Specific location: Specific and identified anatomical location.
Name of location	Name of location: Named anatomical location - ideally would be coded where possible. Default value: Hip
Side	Side: Specify lateraility of the anatomical location. Left Right
Healthcare provider (PARENT)	Healthcare provider (PARENT): Details of a healthcare provider organisation.
Hospital name	Hospital name: The name of the organisation.
Hospital identifier	Hospital 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 name	Department name: The name of a specific department within the organisation.
Exclusion of a Procedure	Exclusion 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 Statement	Exclusion 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 procedure	Current procedure: A generic section header which should be renamed in a template to suit a specific clinical context.
Consent to share information	Consent to share information: Record of status and details of informed consent from a patient (or patient's agent) for a proposed procedure, trial or other healthcare-related activity (including treatments and investigations), based upon a clear appreciation and understanding of the facts, implications, and possible future consequences by the patient or patient's agent.
Procedure/Trial/Activity	Procedure/Trial/Activity: Identification of the procedure, clinical trial or healthcare-related activity (including correct side/correct site, where appropriate) against which the consent status and details are recorded. Default value: Consent to share arthroplasty report
Start Date	Start Date: Date, and optional time, when validity of the informed consent becomes active.
Patient state (Valdoltra only)	Patient state (Valdoltra only): A generic section header which should be renamed in a template to suit a specific clinical context.
Height/Length	Height/Length: Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
Height/Length	Height/Length: The length of the body from crown of head to sole of foot. 0..1000; 0..250 Units: cm in
Body weight	Body weight: Measurement of the body weight of an individual.
Weight	Weight: The weight of the individual. 0..1000 kg
Harris Hip Score	Harris Hip Score: The Harris Hip Score.
Harris Hip Score result	Harris Hip Score result: The result of the Harris Hip Score. 0..100
Grading	Grading: Grading derived from Harris Hip score. Poor Fair Good Excellent
Primary hip arthroplasty	Primary hip arthroplasty: Details of primary hip arthroplasty constrined to align with Slovenian RES register.
Current procedure	Current procedure: The name of the procedure. Total standard hip replacement Total resurfacing hip replacement Partial bipolar hip replacement Partial resurfacing hip replacement
Reason for procedure	Reason for procedure: The reason or indication for the procedure. Primary Osteoarthritis Dysplasia /dysplasia with dislocation Post-Traumatic Aseptic Necrosis of Femoral Head Rheumatoid Arthritis, other arthritis and anylosing spondyilitis Other
Prosthesis fixation	Prosthesis fixation: Identification of specific method or technique used for procedure. Cemented Uncemented Hybrid-cemented stem only Inverse_ Hybrid
Approach	Approach: Identification of specific method or technique used for procedure. Anterior Anterolateral Direct lateral Posterolateral Minimally Invasive
Hip device components	Hip device components: 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 name	Device 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: Hip implant
Acetabular component	Acetabular 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.
Manufacturer device name	Manufacturer device 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.
Type	Type: 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. standard revision [...]
Acetabular component details	Acetabular component details: Additional details of hip arthropasty component.
Cement name	Cement name: The name of the cement used.
Antibacterial in cement?	Antibacterial in cement?: True if antibiotics/antibacterials were added to the cement.
Manufacturer	Manufacturer: Name of manufacturer. Zimmer Endoplus - S&N Link Lima Cremascoli - Wright Biomet J&J Protek Mathys Medacta International Unior Helipro Unknown
Barcode number	Barcode number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Ref number	Ref number: The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Batch/Lot number	Batch/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.
Inlay	Inlay: 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.
Manufacturer device name	Manufacturer device 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.
Type	Type: 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. Standard Anti-luxation
Inlay details	Inlay details: Additional details of hip arthropasty component.
Material	Material: The material used in the manufacture of the arthroplasty component. Polyethilen Cross-linked polyethilen Ceramic Metal
Manufacturer	Manufacturer: Name of manufacturer. Zimmer Endoplus - S&N Link Lima Cremascoli - Wright Biomet J&J Protek Mathys Medacta International Unior Helipro Unknown
Barcode number	Barcode number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Ref. number	Ref. number: The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Batch/Lot number	Batch/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.
Acetabular ring component	Acetabular ring 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.
Manufacturer's device name	Manufacturer's device 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.
Type	Type: 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.
Manufacturer	Manufacturer: Name of manufacturer. Zimmer Endoplus - S&N Link Lima Cremascoli - Wright Biomet J&J Protek Mathys Medacta International Unior Helipro Unknown
Barcode number	Barcode number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Ref number	Ref number: The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Batch/Lot number	Batch/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 component	Head 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.
Manufacturer device name	Manufacturer device 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.
Type	Type: 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. Standard Revision [...]
Femoral Neck component	Femoral Neck 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.
Manufacturer device name	Manufacturer device 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.
Type	Type: 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. Neck alone Neck extended to proximal stem
Manufacturer	Manufacturer: Name of manufacturer. Zimmer Endoplus - S&N Link Lima Cremascoli - Wright Biomet J&J Protek Mathys Medacta International Unior Helipro Unknown
Barcode number	Barcode number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Ref number	Ref number: The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Batch/Lot number	Batch/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 component	Femoral 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.
Manufacturer device name	Manufacturer device 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.
Type	Type: 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. Standard Modular Revision Reconstruction Resurfacing [...]
Femoral component details	Femoral component details: Additional details of hip arthropasty component.
Cement name	Cement name: The name of the cement used.
Antibacterial in cement?	Antibacterial in cement?: True if antibiotics/antibacterials were added to the cement.
Manufacturer	Manufacturer: Name of manufacturer. Zimmer Endoplus - S&N Link Lima Cremascoli - Wright Biomet J&J Protek Mathys Medacta International Unior Helipro Unknown
Barcode number	Barcode number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Ref number	Ref number: The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Batch/Lot number	Batch/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.
Medical Device	Medical Device: 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.
Other device	Other device: 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.
Type	Type: 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.
Description	Description: Narrative description of the medical device.
Manufacturer	Manufacturer: Name of manufacturer.
Barcode number	Barcode number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.
Catalogue number	Catalogue number: The exact number assigned by the manufacturer, as it appears in the manufacturer's catalogue, device labeling, or accompanying packaging.
Batch/Lot number	Batch/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.
Hip procedure registry details (Valdoltra)	Hip procedure registry details (Valdoltra): Additional hip procedure details to align with Valdoltra hospital hip registry.
Trochanter osteotomy	Trochanter osteotomy: Was trochanter osteotomy performed? Trochanter osteotomy performed Trochanter osteotomy not performed
Prophylactic antibiotics	Prophylactic antibiotics: Were prophylactic systemic antibiotics used? Systemic prophylactic antibiotics used Systemic prophylactic antibiotics not used
Wound drainage	Wound drainage: Was wound drainage used? Wound drainage used Wound drainage not used
Duration of procedure	Duration of procedure: The duration of the hip procedure. >=PT0M Minute
Name of location	Name of location: Named anatomical location - ideally would be coded where possible. Default value: Hip
Side	Side: Specify lateraility of the anatomical location. Left Right
Complication	Complication: Details about any complication arising from the procedure.
Procedure identifier	Procedure identifier: 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.
Healthcare provider (PARENT)	Healthcare provider (PARENT): Details of a healthcare provider organisation.
Hospital name	Hospital name: The name of the organisation.
Hospital identifier	Hospital identifier: The unique identifier of the organisation.
Address (ISA)	Address (ISA): Address details compliant with European ISA Standard.
Thoroughfare (street name)	Thoroughfare (street name): An address component that represents the name of a passage or way through from one location to another. A thoroughfare is not necessarily a road, it might be a waterway or some other feature.
Locator Designator (street number0	Locator Designator (street number0: this is the building number, apartment number, etc. For an address such as "Flat 3, 17 Bridge Street", the locator is "flat 3, 17."
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 name	Department name: The name of a specific department within the organisation.
Contact details	Contact details: Contact details for the organisation.