openehr 1.1.1 → 1.1.2

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@@ -0,0 +1,454 @@
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+ archetype (adl_version=1.4)
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+ openEHR-EHR-OBSERVATION.operation_record.v1
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+
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+ concept
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+ [at0000] -- Operation Record
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+ language
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+ original_language = <[ISO_639-1::en]>
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+ description
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+ original_author = <
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+ ["name"] = <"unknown">
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+ >
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+ details = <
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+ ["en"] = <
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+ language = <[ISO_639-1::en]>
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+ purpose = <"To record details pertaining to open or keyhole operation performed">
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+ use = <"">
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+ misuse = <"">
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+ copyright = <"© openEHR Foundation">
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+ >
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+ >
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+ lifecycle_state = <"AuthorDraft">
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+ other_contributors = <>
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+ other_details = <
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+ ["references"] = <"">
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+ >
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+
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+ definition
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+ OBSERVATION[at0000] matches { -- Operation Record
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+ data matches {
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+ HISTORY[at0001] matches { -- Event Series
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+ events cardinality matches {1..*; unordered} matches {
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+ EVENT[at0002] occurrences matches {0..1} matches { -- Any event
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+ data matches {
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+ ITEM_TREE[at0003] matches { -- Tree
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+ items cardinality matches {0..*; unordered} matches {
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+ CLUSTER[at0004] occurrences matches {0..1} matches { -- Incision
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0009] occurrences matches {0..1} matches { -- Skin incision
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+ value matches {
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+ DV_TEXT matches {*}
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+ DV_CODED_TEXT matches {
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+ defining_code matches {
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+ [local::
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+ at0010, -- Midline
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+ at0011, -- Transverse
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+ at0012] -- Classical
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+ }
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+ }
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+ }
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+ }
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+ ELEMENT[at0014] occurrences matches {0..1} matches { -- Location of incision
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0013] occurrences matches {0..1} matches { -- Time of knife to skin
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+ value matches {
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+ DV_DATE_TIME matches {
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+ value matches {yyyy-??-??T??:??:??}
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+ }
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+ }
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+ }
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+ ELEMENT[at0054] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ }
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+ }
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+ CLUSTER[at0037] occurrences matches {0..*} matches { -- Operative details
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0036] occurrences matches {0..1} matches { -- Overall Technique
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ CLUSTER[at0047] occurrences matches {0..1} matches { -- Details of surgery performed
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0044] occurrences matches {0..1} matches { -- Approach
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0049] occurrences matches {0..1} matches { -- Method
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+ value matches {
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+ DV_CODED_TEXT matches {
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+ defining_code matches {[local::]}
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+ }
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+ }
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+ }
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+ ELEMENT[at0045] occurrences matches {0..1} matches { -- Description
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+ value matches {
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+ DV_CODED_TEXT matches {
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+ defining_code matches {[local::]}
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+ }
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+ }
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+ }
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+ ELEMENT[at0050] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_CODED_TEXT matches {
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+ defining_code matches {[local::]}
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+ }
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+ }
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+ }
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+ }
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+ }
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+ CLUSTER[at0042] occurrences matches {0..*} matches { -- Haemostasis
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0043] occurrences matches {0..*} matches { -- Method
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0046] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_CODED_TEXT matches {
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+ defining_code matches {[local::]}
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+ }
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+ }
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+ }
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+ }
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+ }
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+ CLUSTER[at0052] occurrences matches {0..*} matches { -- Operation-specific details
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+ items cardinality matches {0..*; unordered} matches {
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+ allow_archetype CLUSTER[at0055] occurrences matches {0..1} matches {
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+ include
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+ archetype_id/value matches {/.*/}
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+ }
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+ ELEMENT[at0053] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ }
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+ }
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+ ELEMENT[at0038] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ }
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+ }
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+ CLUSTER[at0005] occurrences matches {0..1} matches { -- Closure
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0015] occurrences matches {0..1} matches { -- Number of Closure layers
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+ value matches {
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+ DV_COUNT matches {*}
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+ }
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+ }
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+ CLUSTER[at0016] occurrences matches {0..*} matches { -- Layer closure detail
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0017] occurrences matches {0..1} matches { -- Layer
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+ value matches {
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+ DV_CODED_TEXT matches {
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+ defining_code matches {
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+ [local::
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+ at0020, -- Peritoneum
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+ at0021, -- Sheath
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+ at0022, -- Fat
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+ at0023] -- Skin
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+ }
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+ }
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0018] occurrences matches {0..1} matches { -- Method of closure
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+ value matches {
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+ DV_CODED_TEXT matches {
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+ defining_code matches {
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+ [local::
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+ at0024, -- Suture - continuous
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+ at0025, -- Staples
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+ at0026, -- Suture - subcutaneous
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+ at0027] -- Suture - interrupted
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+ }
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+ }
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+ }
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+ }
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+ ELEMENT[at0019] occurrences matches {0..1} matches { -- Material used
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0030] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ }
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+ }
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+ CLUSTER[at0032] occurrences matches {0..1} matches { -- Drains
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0034] occurrences matches {0..1} matches { -- Type
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0033] occurrences matches {0..1} matches { -- Location
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0035] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_CODED_TEXT matches {
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+ defining_code matches {[local::]}
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+ }
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+ }
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+ }
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+ }
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+ }
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+ ELEMENT[at0051] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ }
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+ }
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+ CLUSTER[at0006] occurrences matches {0..1} matches { -- Intra-Operative Issues
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+ items cardinality matches {0..*; unordered} matches {
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+ ELEMENT[at0007] occurrences matches {0..1} matches { -- Complication
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0008] occurrences matches {0..1} matches { -- Issue or difficulty
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ ELEMENT[at0031] occurrences matches {0..1} matches { -- Comment
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+ value matches {
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+ DV_TEXT matches {*}
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+ }
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+ }
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+ }
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+ }
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+ }
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+ }
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+ }
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+ }
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+ }
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+ }
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+ }
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+ }
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+
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+
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+ ontology
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+ term_definitions = <
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+ ["en"] = <
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+ items = <
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+ ["at0000"] = <
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+ text = <"Operation Record">
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+ description = <"Record of details pertaining to open or keyhole operation performed">
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+ >
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+ ["at0001"] = <
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+ text = <"Event Series">
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+ description = <"@ internal @">
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+ >
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+ ["at0002"] = <
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+ text = <"Any event">
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+ description = <"*">
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+ >
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+ ["at0003"] = <
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+ text = <"Tree">
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+ description = <"@ internal @">
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+ >
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+ ["at0004"] = <
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+ text = <"Incision">
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+ description = <"*">
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+ >
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+ ["at0005"] = <
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+ text = <"Closure">
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+ description = <"*">
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+ >
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+ ["at0006"] = <
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+ text = <"Intra-Operative Issues">
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+ description = <"*">
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+ >
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+ ["at0007"] = <
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+ text = <"Complication">
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+ description = <"Identify any complications incurred in performing the surgery">
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+ >
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+ ["at0008"] = <
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+ text = <"Issue or difficulty">
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+ description = <"Identify any issue or difficulty faced during surgery">
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+ >
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+ ["at0009"] = <
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+ text = <"Skin incision">
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+ description = <"Details about skin incision">
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+ >
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+ ["at0010"] = <
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+ text = <"Midline">
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+ description = <"*">
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+ >
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+ ["at0011"] = <
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+ text = <"Transverse">
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+ description = <"*">
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+ >
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+ ["at0012"] = <
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+ text = <"Classical">
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+ description = <"*">
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+ >
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+ ["at0013"] = <
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+ text = <"Time of knife to skin">
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+ description = <"*">
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+ >
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+ ["at0014"] = <
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+ text = <"Location of incision">
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+ description = <"Location of incision">
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+ >
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+ ["at0015"] = <
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+ text = <"Number of Closure layers">
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+ description = <"*">
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+ >
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+ ["at0016"] = <
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+ text = <"Layer closure detail">
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+ description = <"*">
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+ >
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+ ["at0017"] = <
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+ text = <"Layer">
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+ description = <"Name of layer">
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+ >
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+ ["at0018"] = <
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+ text = <"Method of closure">
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+ description = <"Method of closure">
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+ >
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+ ["at0019"] = <
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+ text = <"Material used">
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+ description = <"Details about closure material">
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+ >
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+ ["at0020"] = <
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+ text = <"Peritoneum">
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+ description = <"*">
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+ >
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+ ["at0021"] = <
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+ text = <"Sheath">
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+ description = <"*">
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+ >
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+ ["at0022"] = <
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+ text = <"Fat">
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+ description = <"*">
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+ >
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+ ["at0023"] = <
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+ text = <"Skin">
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+ description = <"*">
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+ >
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+ ["at0024"] = <
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+ text = <"Suture - continuous">
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+ description = <"*">
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+ >
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+ ["at0025"] = <
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+ text = <"Staples">
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+ description = <"*">
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+ >
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+ ["at0026"] = <
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+ text = <"Suture - subcutaneous">
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+ description = <"*">
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+ >
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+ ["at0027"] = <
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+ text = <"Suture - interrupted">
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+ description = <"*">
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+ >
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+ ["at0030"] = <
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+ text = <"Comment">
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+ description = <"Additional comment about closure">
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+ >
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+ ["at0031"] = <
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+ text = <"Comment">
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+ description = <"Additional comment about operative issues">
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+ >
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+ ["at0032"] = <
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+ text = <"Drains">
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+ description = <"Detail about drains inserted">
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+ >
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+ ["at0033"] = <
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+ text = <"Location">
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+ description = <"Location of drain">
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+ >
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+ ["at0034"] = <
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+ text = <"Type">
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+ description = <"Type of drain">
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+ >
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+ ["at0035"] = <
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+ text = <"Comment">
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+ description = <"Comment about drains">
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+ >
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+ ["at0036"] = <
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+ text = <"Overall Technique">
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+ description = <"Details of operative technique performed">
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+ >
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+ ["at0037"] = <
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+ text = <"Operative details">
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+ description = <"*">
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+ >
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+ ["at0038"] = <
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+ text = <"Comment">
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+ description = <"Overall comment about the operation performed">
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+ >
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+ ["at0042"] = <
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+ text = <"Haemostasis">
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+ description = <"Details about haemostasis methods used">
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+ >
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+ ["at0043"] = <
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+ text = <"Method">
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+ description = <"Method of haemostasis">
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+ >
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+ ["at0044"] = <
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+ text = <"Approach">
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+ description = <"Surgical approach">
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+ >
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+ ["at0045"] = <
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+ text = <"Description">
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+ description = <"Details of surgery performed">
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+ >
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+ ["at0046"] = <
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+ text = <"Comment">
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+ description = <"*">
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+ >
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+ ["at0047"] = <
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+ text = <"Details of surgery performed">
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+ description = <"*">
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+ >
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+ ["at0049"] = <
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+ text = <"Method">
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+ description = <"Details of method performed">
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+ >
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+ ["at0050"] = <
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+ text = <"Comment">
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+ description = <"Comments about surgery performed">
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+ >
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+ ["at0051"] = <
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+ text = <"Comment">
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+ description = <"Comments about closure">
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+ >
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+ ["at0052"] = <
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+ text = <"Operation-specific details">
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+ description = <"Further details about operation that are very specific to purpose">
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+ >
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+ ["at0053"] = <
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+ text = <"Comment">
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+ description = <"Comment on operation-specific details">
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+ >
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+ ["at0054"] = <
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+ text = <"Comment">
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+ description = <"Comment about the incision and opening phase of surgical operation">
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+ >
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+ ["at0055"] = <
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+ text = <"Any operation-specific details">
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+ description = <"Cluster for further details about operation that are very specific to purpose">
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+ >
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+ >
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+ >
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+ >