ARCHETYPE Operation Record (openEHR-EHR-OBSERVATION.operation_record.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.operation_record.v1
ConceptOperation Record
DescriptionRecord of details pertaining to open or keyhole operation performed
PurposeTo record details pertaining to open or keyhole operation performed
References
Copyrightcopyright (c) 2009 openEHR Foundation
AuthorsAuthor name: unknown
Other Details LanguageAuthor name: unknown
Other Details (Language Independent)
  • References:
Keywords
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.63
events
Any eventAny event: *
data
IncisionIncision: *
Skin incisionSkin incision: Details about skin incision
Choice of:
  •  Text
  •  Coded Text
    • Midline [*]
    • Transverse [*]
    • Classical [*]
Location of incisionLocation of incision: Location of incision
Time of knife to skinTime of knife to skin: *
CommentComment: Comment about the incision and opening phase of surgical operation
Operative detailsOperative details: *
Overall TechniqueOverall Technique: Details of operative technique performed
Details of surgery performedDetails of surgery performed: *
ApproachApproach: Surgical approach
MethodMethod: Details of method performed
DescriptionDescription: Details of surgery performed
CommentComment: Comments about surgery performed
HaemostasisHaemostasis: Details about haemostasis methods used
MethodMethod: Method of haemostasis
CommentComment: *
Operation-specific detailsOperation-specific details: Further details about operation that are very specific to purpose
Any operation-specific detailsAny operation-specific details: Cluster for further details about operation that are very specific to purpose
Include:
All not explicitly excluded archetypes
CommentComment: Comment on operation-specific details
CommentComment: Overall comment about the operation performed
ClosureClosure: *
Number of Closure layersNumber of Closure layers: *
Layer closure detailLayer closure detail: *
LayerLayer: Name of layer
Choice of:
  •  Coded Text
    • Peritoneum [*]
    • Sheath [*]
    • Fat [*]
    • Skin [*]
  •  Text
Method of closureMethod of closure: Method of closure
  • Suture - continuous [*]
  • Staples [*]
  • Suture - subcutaneous [*]
  • Suture - interrupted [*]
Material usedMaterial used: Details about closure material
CommentComment: Additional comment about closure
DrainsDrains: Detail about drains inserted
TypeType: Type of drain
LocationLocation: Location of drain
CommentComment: Comment about drains
CommentComment: Comments about closure
Intra-Operative IssuesIntra-Operative Issues: *
ComplicationComplication: Identify any complications incurred in performing the surgery
Issue or difficultyIssue or difficulty: Identify any issue or difficulty faced during surgery
CommentComment: Additional comment about operative issues
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