Narrative patient data relevant to the context identified by note types.

Data Element
Operative Note
Description

Summary of a surgical procedure.

Usage note: May include procedures performed, operative and anesthesia times, findings observed, fluids administered, specimens obtained, and complications identified.
Submitted By: Leslie Kelly Hall / Engaging Patient Strategy
Data Element Information
Rationale for Separate Consideration Very high benefit and low risk. Known LOINC codes and current work flows and exchange in place. https://loinc.org/LG38755-1/
Use Case Description(s)
Use Case Description Consistent with Clinical notes, view download and transport and the desires of information sharing, OP notes is a necessary component for access and
Estimate the breadth of applicability of the use case(s) for this data element Approximately 51% of all hospital visits under Medicare include a procedure that includes an operative note. Cancer patients and their supporting clinical team members, count on OP notes for continuity of care and transitions.
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) https://loinc.org/LG38755-1/
https://loinc.org/LG38755-1/
Additional Specifications N/A
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts Every EMR contains an OP note for every operative procedure.
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts This is commonly collected but not specifically called out in USCDI.
As a patient advocate, I do not have access to the artifacts.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) None.
Restrictions on Use (e.g. licensing, user fees) None.
Privacy and Security Concerns None.
Estimate of Overall Burden Very little burden. Codes, creation, storage and standards are in place.
Other Implementation Challenges none
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by rbaker@cdisc.org on

Clarify the difference between a "Operative Note" and "Procedure

In hospitals, there are "Operative Notes" that occur in the "Operating Room" or "Surgery" and there are "Procedures that occur in "Interventional Radiology" and the "Cardiac Catheterization Laboratory" or the "Electrophysiology Lab". There are cases where procedures done in the operating room resemble those done in a procedure room. The notes are similar to the area.  Standardly speaking, should an "Operative Note" mean there was an "incision" or "opening of a body cavity" and the "Procedure Note mean" these were done in a "non-invasive fashion"?  Does the fact that "Anesthesia" was there make a difference? In most surgery cases, "Anesthesia" is involved while in the other cases the nurses administer the sedation unless there is high risk with the sedation or the procedure and airway concerns.
There are cases in the intensive care unit (ICU) where invasive surgeries and procedures occur at the bedside. They are often "free text" in the progress notes. The may have "Operative Note" as a header OR "Procedure Note" as a header. Examples, "Tracheotomy", "Insertion of Triple Lumen Catheter", "Insertion of Invasive Heart Pressure Monitoring (Swan-Ganz) Cathether", "Endotracheal intubation". How would these be categorized?

Loinc code - https://loinc.org/11504-8

These components are found in operative notes. The term "surgery" is defined as "the setting". However, as noted above there is overlap dependent on healthcare organization and hospital which may vary depending on location and both national and international definitions of these terms. 
 

Existing Text:

Defined as: 
"Summary of surgical procedure." 
"Usage note: May include procedures performed, operative and anesthesia times, findings observed, fluids administered, specimens obtained, and complications identified."

Proposed Text:

Defined as:
"Summary of surgical procedure defined as involving an incision and the removal or replacement of a diseased organ or tissue"
Consider, "requiring anesthesia"?
(no change recommended to "Usage note")

Submitted by hswmin on

THIA Support for Operative Note

The Texas Health Informatics Alliance (THIA) Policy and Standards Working group are pleased to see that operative (OR) notes are called out as separate encounters to ease the burden of clinicians in locating clinical records in an expeditious manner. Currently, OR notes are linked with procedure notes in the EHR and they all run together. Having OR notes called out from procedures is important as they are of higher risk.

Moreover, we would like to emphasize our support for the automation of reporting and homogenization of requests to remove some of the reporting burden on hospitals. Replication of the same data is often asked for by multiple government agencies, including the implant registry and requirement of hospitals to keep track of implants.

THIA Policy & Standards WG - USCDI v5 Recommendations - Clinical Notes - Operative Note.pdf

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