| ARCHETYPE ID | openEHR-EHR-ACTION.procedure-CSP.v0 |
|---|---|
| Concept | Procedure undertaken (CSP) |
| Description | A clinical activity that has been carried out for therapeutic or diagnostic purposes. |
| Use | Use to record detailed information about the procedure that has been carried out on an individual. Information about activities related to the procedure, such as anaesthesia or administration of medications, should be recorded in separate ACTION archetypes. |
| Purpose | To record details about a procedure that has been performed. |
| References | |
| Copyright | © copyright (c) 2010 openEHR Foundation, openEHR Foundation |
| Authors | Author name: Ian McNicoll Organisation: Ocean Informatics, United Kingdom Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 03/12/2009 |
| Other Details Language | Author name: Ian McNicoll Organisation: Ocean Informatics, United Kingdom Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 03/12/2009 |
| Other Details (Language Independent) |
|
| Keywords | procedure |
| Lifecycle | in_development |
| UID | 77d4a3c7-f97f-4761-8968-d6b48dc8d8e4 |
| Language used | en |
| Citeable Identifier | 1013.1.2052 |
| Revision Number | 0.0.1-alpha |
| ism_transition | |
| Request initiated | Request initiated: Request for procedure is initiated. Current state: planned |
| Request sent | Request sent: Request for procedure sent. Current state: planned |
| Request postponed | Request postponed: Request for procedure is postponed. Current state: postponed |
| Request cancelled | Request cancelled: Procedure request has been cancelled. Current state: cancelled |
| Procedure scheduled | Procedure scheduled: Procedure has been scheduled. Current state: scheduled |
| In progress | In progress: Procedure is being carried out. Current state: active |
| Procedure suspended | Procedure suspended: Procedure has been suspended. Current state: suspended |
| Procedure aborted | Procedure aborted: Procedure has been aborted. Current state: aborted |
| Completed | Completed: Procedure has been completed. Current state: completed |
| Report authored | Report authored: Procedure report has been written. Current state: completed |
| Report attested | Report attested: Procedure report has been attested. Current state: completed |
| Report sent | Report sent: Procedure report has been distributed. Current state: completed |
| protocol | |
| Requestor order identifier | Requestor order identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. |
| Requestor | Requestor: Details about the healthcare provider or organisation requesting the service. Include: All not explicitly excluded archetypes |
| Receiver order identifier | Receiver order 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. |
| Receiver | Receiver: Details about the healthcare provider or organisation receiving the request for service. Include: All not explicitly excluded archetypes |
| Performed by healthcare worker category | Performed by healthcare worker category: Category of healthcare worker that performed the procedure. To be used in CHRISP for reporting purposes and where the identity of the performing person is not known at the time data is collected. (i.e. Device inserted by). |
| Performed by IV team member | Performed by IV team member: Indicate 'yes'/'no' if the performer of the procedure was part of the IV team. |
| description | |
| ! - Procedure | ! - Procedure: The name of the procedure. |
| ! - Reason/s for procedure | ! - Reason/s for procedure: The reason or indication for the procedure. |
| Method/Technique | Method/Technique: Identification of specific method or technique used for procedure. |
| Description | Description: Narrative description about the procedure carried out. |
| Procedure Details | Procedure Details: Detailed structure describing the procedure carried out, including preparation and details about the method and equipment/devices used. Include: All not explicitly excluded archetypes |
| Anatomical site details | Anatomical site details: Details about the anatomical site of procedure. Include: All not explicitly excluded archetypes |
| Additional tasks | Additional tasks: Record information about unplanned or unexpected activities that needed to be done during the procedure. Record the name of the task and a description within this archetype, but detail should be recorded in specific linked INSTRUCTION or ACTION archetypes. |
| Task | Task: Name of additional task performed during the procedure. |
| Task description | Task description: Description of additional task performed during the procedure. |
| Record of additional task | Record of additional task: Link to a detailed record of the additional task. |
| Outcome | Outcome: Outcome of procedure performed. |
| Procedure unsuccessful | Procedure unsuccessful: Was the procedure ultimately unsuccessful? True if unsuccessful. Allowed values: {true} |
| Failed attempts | Failed attempts: The number of failed attempts to perform the procedure. |
| Unplanned event | Unplanned event: An unplanned event prior to or related to the procedure, which may affect its execution e.g patient self-removed cannula. |
| Complication | Complication: Details about any complication arising from the procedure. |
| Emergency? | Emergency?: Was this procedure performed as an emergency? True if Yes. |
| Comments | Comments: Comments about the procedure. |
| Multimedia | Multimedia: Multimedia representation of the procedure, including images. |
| Other contributors | Heather Leslie, Ocean Informatics, Australia |
| Translators |