Submitted by rbaker@cdisc.org on
Synopsis of non-operative procedure.
It is odd that the "Procedure Note" is defined as "non-operative". If there was a category for "Operative Reports" this would make since, but there isn't. Where is the "Operative Report" or "OR Report" expected to be? It seems like this is the most relevant "Date Element" under the "Clinical Notes" section. "Procedure" in the greater context of data interoperability and data structures usually includes both "non-operative" and "operative". In the paper chart world, we kept them separate but they each had a section (currently, USCDI does not have a section). the structure of these two items is the same too. Two examples are included at these links: (https://training.seer.cancer.gov/abstracting/procedures/operative/example/ex4.html) and (http://jaccjacc.cardiosource.com/DataSupp/2014_Cathlab_CathReportSample.pdf)
This link is clinical research focused but could be applied generally https://raw.githubusercontent.com/CBIIT/bridg-model/master/Documents/For%20Website/NEW%20Performing%20a%20Surgical%20Procedure.png
BRIDG was an initiative that included HL7, ISO, NIH, NCI, FDA and CDISC (maybe others). It is based on the HL7 RIM model. https://bridgmodel.nci.nih.gov/model-subset
In the diagram under FoundationClasses Subject Area Procdure is noted - https://vico.org/HL7_RIM/index.html
Thank you for considering the update to the definition of Procedure Note.
Submitted by rbaker@cdisc.org on
Clarify the difference between a "Operative Note" and "Procedure
Currently, Procedure note is defined as:
"Summary of non-operative procedure."
"Examples include but are not limited to interventional cardiology, gastrointestinal endoscopy, and osteopathic manipulation."
Proposed Text is defined as:
"Summary of non-invasive procedure where the diagnostic or therapeutic procedure is done using tubes and catheters without incision to remove, repair or examine diseased organ or tissue."
(no change recommended to "example sentence".
Rationale (similar to the comment in Operative notes with additional text from LOINC codes.
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?
For operative note
For procedures:
LP74249-1 Procedure note
Procedure note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient's tolerance of the procedure. Source: HL7
These components are found in op 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