Diskussion:
Utifrån informationen som beskrivs är de ¨åtgärder som åsyftas framför allt kirurgiska ingrepp. Det kommer därför även framför allt att röra sig om redan utförda åtgärder. Antagandet är att information om pågående och planerade åtgärder kommer vara fritext som är svår att urskilja från andra uppgifter. Därför kan ett bättre namn på avsnittet vara "åtgärder".
Svenska klassifikationssystem:
- hieraki åtgärder i Snomed CT (kod från << 71388002 | åtgärd |)
- Klassifikation av vårdåtgärder (KVÅ)
- Klassifikation av medicinska åtgärder (KMÅ)
- Klassifikation av kirurgiska åtgärder (KKÅ)
Går det att beskriva täckningsgrad mm för dessa i dagens journaler?
Vad utbyts idag via tjänstekontraktet GetActivities?
Hypotes om att operationsplaneringssystem är anslutna till kvalitetsregister. Går det att hitta synergier mellan dessa anslutningar och informationsförsörjning till en patientöversikt?
Från kravkatalogen i MyHealth@EU beskrivs procedures enligt nedan. Kan vi anta att det är samma för EHDS?
Describes the type of the procedure, surgical or non-surgical.
Procedures may refer for example to:
- Invasive Diagnostic procedure: e.g. Cardiac catheterization;
- Therapeutic procedure: e.g. dialysis;
- Surgical procedure: e.g. appendectomy;
Genomförda och planerade
I MyHealth@EU beskrivs både genomförda och planerade: "The procedure entry is used to record procedures that have occured, or which are planned for in the future."
Status
Ser ut som en "status" är borttaget jämfört med MyHealth@EU:
"This element shall be present when used to describe a procedure event. It shall have the value 'completed' for procedures that have been completed and 'active' for procedures that are still in progress. Procedures that were stopped prior to completion shall use the value 'aborted', and procedures that were cancelled before being started shall use the value 'cancelled'"
Även "prioritet" är borttaget:
eHN Guidelines
| Data | Description | Preferred Code Systems | Arbetsgruppens ("Svensk") tolkning av informationselementet | Utvärderingsparametrar | De nationella tjänstekontrakten | ||
| * ** A.2 Patient summary body data elements | |||||||
| A.2.3.3 Procedures | Ur uppdragsbeskrivning: •Socialstyrelsens arbete med kodverk för åtgärder (KVÅ) och mappning med internationella standarder som SNOMED CT fortsätter. | ||||||
| A.2.3.3.1 Procedure description | Describes the type of procedure | SNOMED CT GPS* | Beskrivning av hur lösningen möter EDHS krav | ||||
| Bedömning | |||||||
| Täckningsgrad | |||||||
| Kvalité på informationen | |||||||
| A.2.3.3.2 Body site | Procedure target body site | SNOMED CT GPS* | Beskrivning av hur lösningen möter EDHS krav | ||||
| Bedömning | |||||||
| Täckningsgrad | |||||||
| Kvalité på informationen | |||||||
| A.2.3.3.3 Procedure date | Date when procedure was performed | ISO 8601 | Beskrivning av hur lösningen möter EDHS krav | ||||
| Bedömning | |||||||
| Täckningsgrad | |||||||
| Kvalité på informationen | |||||||
* In a foreseeable future, the suggested preferred vocabularies might be superseded or
complemented, as mentioned in Guidelines Article 11(2).
** The Preferred code system(s) has been selected based on adequacy to convey the
information using the methodology of the Subgroup on Semantics. When more alternative
international code systems are available, all are listed when it is assumed to be unlikely that
agreement can be reached short term. Mapping between code systems could be proposed for
specific use cases.
Xt-EHR Logical Model
| Short | Definition | Min | Max | Type(s) | Binding Strength | Binding Description | E-hälsomyndigheten (arbete med PS MyHealth@EU, land B) | |||
| B.1.3.4 - Procedures section | Procedures section | 0 | 1 | Base | ||||||
| B.1.3.4.1 - Subsection narative | Narative content of the subsection. | 0 | 1 | string | ||||||
| B.1.3.4.2 - Procedures | Major procedures. | 1 | * | EHDSProcedure | Benämning: "Åtgärder" |
| Short | Definition | Min | Max | Type(s) | Binding Strength | Binding Description | E-hälsomyndigheten (arbete med PS MyHealth@EU, land B) | ||
| Procedure model | C.16 - EHDS refined base model for An action that is or was performed on or for a patient | 0 | * | ||||||
| C.16.1 - Identifier | Procedure identifier | 0 | * | Identifier | Visas ej i gränssnittet | ||||
| C.16.2 - Description | Procedure specification in string form | 0 | 1 | string | |||||
| C.16.3 - Code | Code identifying the procedure | 0 | 1 | CodeableConcept | preferred | SNOMED CT | Benämning: "Åtgärd" Snomed CT | ||
| C.16.4 - Date | Date and time of the procedure or interval of its performance | 0 | 1 | dateTime Period | Benämning: "Utförd" | ||||
| C.16.5 - Performer | An actor who or what performed the procedure | 0 | * | Reference(Health professional model) | saknas | ||||
| C.16.6 - Anatomic location | Anatomic location and laterality where the procedure was performed. This is the target site. | 0 | * | CodeableConcept | preferred | SNOMED CT, ICD-O-3 | Benämning: "Kroppsdel" | ||
| C.16.7 - Reason | The reason why the procedure was performed. | 0 | * | Reference(Condition model|Observation model| Procedure model) | ev. internal reference? Har inte med det i gränssnittet idag. | ||||
| C.16.8 - Outcome | The outcome of the procedure - did it resolve the reasons for the procedure being performed? | 0 | 1 | CodeableConcept | preferred | SNOMED CT | saknas | ||
| C.16.9 - Complication | Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the procedure description, which will typically describe the procedure itself rather than any 'post procedure' issues. | 0 | * | CodeableConcept | preferred | ICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed | saknas | ||
| C.16.10 - Device used | Device used to perform the procedure | 0 | * | EHDSDevice | saknas | ||||
| C.16.11 - Focal device | Device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure. | 0 | * | Reference(Device model) | saknas | ||||
| C.16.12 - Location | Location where the procedure had been performed | 0 | * | EHDSLocation | saknas | ||||
| C.16.13 - Note | Additional information about the procedure | 0 | 1 | string | saknas | ||||
| C.16.14 - Patient | On whom or on what the procedure was performed. This is usually an individual human, but can also be performed on animals, groups of humans or animals, organizations or practitioners (for licensing), locations or devices (for safety inspections or regulatory authorizations). If the actual focus of the procedure is different from the subject, the focus element specifies the actual focus of the procedure. | 1 | 1 | Reference(Patient model |Location model|Device model |Organization model|Health professional model|Group model) | Patient |