Evaluation of anaesthetic risk: Evaluation

Generated by the Ocean HTML generator: 25/05/2006 Comments to Ocean Informatics Copyright openEHR Foundation © 2006

Concept

Archetype Id

Structure

Evaluation to indicate that there is, or is not, a significant added risk to this person having an anaesthetic Id: openEHR-EHR-EVALUATION.risk-anaesthetic.v1
Reference model: EHR
ADL

Data

Protocol


Data: TREE

Concept


Ordered

Description

Type

Cardinality

Values

Type of anaesthetic (specialisation of: Index condition) The condition on which the risk assessment is focussedCoded text
mandatory
1..1
any anaesthetic
general
spinal/epidural
local
regional
sedation
Significance of risk The likelihood that this person will develop this condition or suffer in this way in the futureCoded text
optional
0..1
Not significant
Minimal significance
Significant
Highly significant
Rationale Justification for this risk assessmentText
optional
0..1
Free or coded text
Indicators, Specific indications of risk.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Age at surgery Age at expected date of surgeryQuantity
optional
0..1
Property = TIME
Units:
   mo, (>= 0)
   yr, (>= 0)
   h, (>= 0)
   d, (>= 0)
Previous anaesthetic, *.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Difficult intubation The patient has a history of difficult intubationBoolean
optional
0..1
True
Difficult ventilation Patient has proved to be difficult to ventilate in the pastBoolean
optional
0..1
True
Severe post-op nausea and vomiting Severe nausea and vomiting following surgery/anaesthesiaBoolean
optional
0..1
True
Malignant hyperthermia Previous malignant hyperthermiaBoolean
optional
0..1
True
Pseudocholinesterase abnormality Abnormal enzyme activity Boolean
optional
0..1
True
Life threatening intra-operative event Life threatening event during surgery such as cardiac arrest, anaphylaxis or bronchospasmBoolean
optional
0..1
True
Pain management difficulties Difficulty managing pain following surgery in the pastBoolean
optional
0..1
True
Difficult venous access Difficulty obtaining venous access prior to inductionBoolean
optional
0..1
True
Previous awareness Episode of being aware during anaesthesiaBoolean
optional
0..1
True

Significant co-morbidity, *.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

condition Condition wihich adds significantly to anaesthetic riskText
optional, repeating
0..*
Free or coded text

Concept

Description

Type

Cardinality

Values

Behavioural problem Patient is difficult to manage for other reasons - e.g. intellectual disabilityBoolean
optional
0..1
True
Obstructive sleep apnoea Diagnosis and/or symptoms of significant sleep apnoeaBoolean
optional
0..1
True
Significant drug allergy Allergy to agent that may be used during the peri-operative periodBoolean
optional
0..1
True
Latex allergy Proven or suspected allergy to latex or fruit with cross-sensitivityBoolean
optional
0..1
True
Recent infection Recent infection that could compromise the person during anaesthesia or surgeryBoolean
optional
0..1
True
Medications, *.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Anticoagulants Patient taking any medication which alters coagulationBoolean
optional
0..1
True
Diuretics The person is taking any medication containing a diureticBoolean
optional
0..1
True
Steroids Person is taking oral steroids currently or in past monthBoolean
optional
0..1
True
Digoxin Person is taking digoxinBoolean
optional
0..1
True
Regular opiates Person is being prescribed regular opiatesBoolean
optional
0..1
True

Social/recreational drugs, *.       Cluster (0..1) optional
 

Concept

Description

Type

Cardinality

Values

Smoker >20 pack years Patient has smoked more than 20 pack years, whether current smoker or notBoolean
optional
0..1
True
Alcohol >40 std drinks/wk Patient drinks more than 40 standard drinks per weekBoolean
optional
0..1
True
Other drug use Patient is using other drugs on a regular basisBoolean
optional
0..1
True

Concept

Description

Type

Cardinality

Values

BMI > 35 Body mass index is greater than 35Boolean
optional
0..1
True
Booked for major surgery ??Boolean
optional
0..1
True


Protocol: LIST

Concept

Description

Type

Cardinality

Values

Risk calculation The means of calculating the riskText
optional
0..1
Free or coded text

Supported by the General Practice Computing Group of Australia through funding from the Commonwealth Department of Health and Ageing