Requirements Specification for Operations And Significant Procedures
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| Descriptions of new and relevant therapeutic operations and procedures, including any complications and adverse events arising
during the procedure.
Note: Procedures that are both therapeutic and investigative may appear either in this section or in the Investigations section
or in both, at the author’s discretion.
Requirement References:
- A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications
when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008).
- Requirement for ‘details of any clinical procedure undertaken’ in 2011/12 Standard Terms and Conditions for Acute Hospital
Services (Department of Health, April 2011).
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Procedure Performed Date
Business DefinitionThe start date and optionally time when the procedure was performed.
Requirement Reference LRA DS expert group 2011 – clinically useful for follow-up care.
Proposed Data ValuesA string with the format "YYYYMMDDHHMMSS.UUUU[+|-ZZzz]".
Data UseClinical audit / research, continuing care.
Data SourceCopied from previous record entry.
Available Data StandardsISO 11404 - Point in Time, NHS ISB 1502: Common User Interface - Date and Time Input, NHS ISB 1503: Common User Interface
- Date Display, NHS ISB 1501: Common User Interface - Time Display.
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Procedure Description
Business DefinitionA description of the therapeutic procedure performed. The procedure description could include the site and should include
laterality where applicable. It may also include the status of the procedure and priority information, at the discretion of
the author.
For data entry, some sites may prefer to require authors to enter some of the description separately (e.g. laterality) where
it is applicable. The communication form, however, should be a single expression.
Requirement Reference
- A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications
when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008).
- Medicines Reconciliation: A Guide to Implementation (National Prescribing Centre, 2008).
Proposed Data ValuesCoded expression for name, site, laterality and potentially also status and priority. The intent is to use codes wherever
applicable (to allow automated record updates and analyses), but where authors want to add free text annotation, this should
also be supported. Where no appropriate code exists, this value should be free text. (Note that free text data would not be
accessible to automated interpretation).
- Name
- Site
- Laterality
- Post-starting action status (at time of discharge):
*Suspended
*Performed (Done)
*Discontinued (Stopped before completion)
*Abandoned (Stopped before completion)
[Context values for actions_EDC_19032009.doc]
- Priority
* Immediate
* Urgent
* Elective
* Scheduled
Data UseClinical audits / research, continuing care.
Data SourceCopied from previous record entry.
Data Examples
- Elective, Right colectomy, performed
- Emergency, Appendectomy, performed
- Insertion of Chest Drain, right
Available Data StandardsSNOMED CT.
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Consultant Responsible Name
Business DefinitionThe consultant responsible for undertaking the procedure.
Requirement Reference LRA DS expert group 2011 – useful for potential follow-up contact.
Proposed Data Values[Prefixes][Given names][Family names][Suffixes].
Data UseFollow-up contact.
Data SourcePrevious record entry.
Available Data StandardsISO 21090 Health informatics data types, HL7 V3 Data Types, NHS MIM data types.
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Consultant Responsible ID
Business DefinitionThe Consultant’s identification code.
Requirement Reference LRA DS expert group 2011 – to add precision to Consultant Responsible Name.
Proposed Data ValuesConsultant unique identifier.
Data UseClinical audit, continuing care.
Data SourceCopied from previous record entry.
Available Data StandardsGeneral Medical Council code.
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Indications For Procedure
Business DefinitionThe primary clinical reason(s) for the procedure performed.
Requirement Reference LRA DS expert group 2011 – allowance for additional detail at the discretion of the author.
Proposed Data ValuesCoded expressions for diagnosis, finding or problem also recorded elsewhere in the Discharge Summary. The intent is to use
codes wherever applicable (to allow automated record updates and analyses), but where authors want to add free text annotation,
this should also be supported. Where no appropriate code exists, this value should be free text. (Note that free text data
would not be accessible to automated interpretation).
Data UseClinical audit, continuing care.
Data SourceCopied from previous record entry.
Data Examples
- Carcinoma of hepatic flexure
- Abdominal pain, left iliac fossa
- Right Pneumothorax
Available Data StandardsSNOMED CT.
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Procedure Comments
Business DefinitionAny additional comments about a procedure.
Requirement Reference LRA DS expert group 2011 – allowance for additional detail at the discretion of the author.
Proposed Data ValuesFree text.
Data UseContinuing care.
Data SourceCopied from previous record entry.
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Complications During Procedure
Business DefinitionDetails of any intra-operative complications encountered during the procedure or arising during the patient’s stay in the
recovery unit.
Requirement Reference A Clinician’s Guide to Record Standards – Part 2: Standards for the structure and content of medical records and communications
when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008).
Proposed Data ValuesA coded expression describing the complication. The intent is to use codes wherever applicable (to allow automated record
updates and analyses), but where authors want to add free text annotation, this should also be supported. Where no appropriate
code exists, this value should be free text. (Note that free text data would not be accessible to automated interpretation).
Data UseClinical audit / research, continuing care.
Data SourceCopied from procedure record.
Data Examples
- Cardiac arrest
- Fracture of femur (during hip replacement)
- Liver laceration (during cholecystectomy)
Available Data StandardsSNOMED CT.
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