Pre-operative record!: Observation

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Record of details pertaining to pre-operative preparation !

Id: openEHR-EHR-OBSERVATION.pre_operative-caesarean_section.v1draft
Reference model: EHR
ADL, (ADL)

History

Protocol

Data

State

Data: TREE

Concept	Description	Type	Cardinality	Values
Indication	Indication for surgery	*Text*	optional 0..1	Free or coded text
Intended Operation	Name of operation intended to be performed at commencement of operation	*Text*	optional, repeating 0..*	Free or coded text
Urgency of operation	Elective or emergency	Coded text Ordinal Text Coded text Coded text Boolean	optional 0..1	Elective Emergency Operator Operator assistant Anaesthetist Anaesthetist assistant Scrub nurse Nurse Medical student Student nurse Orderly Observer Free or coded text Free or coded text True, False
Type of anaesthetic	Type of anaesthetic	*Text*	optional 0..1	Free or coded text

Patient preparation checklist, *. Cluster (0..1) optional

Concept	Description	Type	Cardinality	Values
Urinary Catheter in situ?	Does patient have urinary catheter in in situ?	*Boolean*	optional 0..1	True, False
Known haemoglobin result?	Known pre-operative Haemoglobin?	*Boolean*	optional 0..1	True, False
Blood group and save?	Was blood group and save performed prior to surgery?	*Boolean*	optional 0..1	True, False
Blood cross-matched?	Was blood cross-matched prior to surgery?	*Boolean*	optional 0..1	True, False
Pre-operative heparin?	Was patient given pre-operative heparin?	*Boolean*	optional 0..1	True, False
Pre-operative antibiotics	Was patient given pre-operative antibioticsa?	*Boolean*	optional 0..1	True, False
Other	Other unspecified check	*Any*	optional 0..1

Pre-operative Examination findings, *. Cluster (0..1) optional

Slot	Type	Occurrences	Constraints
	CLUSTER	0..*	Include entries openEHR-EHR-CLUSTER.exam-abdomen.v1 openEHR-EHR-CLUSTER.exam-fetus.v1 openEHR-EHR-CLUSTER.exam-uterus.v1 openEHR-EHR-CLUSTER.exam-uterine_cervix.v1

Events: HISTORY

Events	Description	Constraints	Values
Any event	*	PointInTime 0..1

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