Unique Agenda Items
1) Surgery notes
2) Procedure Notes
2) Isabel
| Preferred | Roll Up Term | Summary | |
|---|---|---|---|
| Kind of Document | Note | Note | Note |
| Type of Service | Surgical Operation Note | Surgical Operation Note | Surgical Operation Note |
| Subject Matter Domain | Restricted to those who do surgery | Suppressed | Restricted to those who do surgery |
| Role | Suppressed | Suppressed | Suppressed |
| Setting | Only =Hospital, =Outpatient, =Emergency Department | Suppressed | Hospital typically |
| LOINC | None for Setting = Hospital | 11504-8 | Need some |
| Display Guideline | Replace "Surgical Operation Note" with "Operative Note" Remove "Hospital" Remove "Note" Replace "Outpatient Clinic" with "Clinic" | Replace "Surgical Operation Note" with "Operative Note" Remove "Note" | Replace "Surgical Operation Note" with "Operative Note" Remove "Hospital" Remove "Note" Replace "Outpatient Clinic" with "Clinic" |
| Note | A) Urology Operative Clinic Note or B) Urology Clinic Operative Note |
| Preferred | XAllowable | Roll Up Term | Summary | |
|---|---|---|---|---|
| Kind of Document | Note | Note | Note | Note |
| Type of Service | Procedure Note | Procedure Note | Procedure Note | Procedure Note |
| Subject Matter Domain | Any | Any | Suppressed | Any |
| Role | Restricted to Any except physician roles such as Medical Student, Attending, Physician, Fellow, Resident | Restricted to Any except physician roles such as Medical Student, Attending, Physician, Fellow, Resident | Suppressed | Suppressed |
| Setting | Any | Any | Suppressed | =Hospital or =Outpatient typically |
| LOINC | Few for Setting = Hospital or Outpatient | Few for Setting = Hospital or Outpatient | 28570-0 | Need many |
| Display Guideline | Remove "Hospital" Remove "Note" x2 Replace "Outpatient Clinic" with "Clinic" | Remove "Hospital" Remove "Note" x2 Replace "Outpatient Clinic" with "Clinic" | Remove "Note" x2 | Remove "Hospital" Remove "Note" x2 Replace "Outpatient Clinic" with "Clinic" |
| Note | A) Urology Procedure Clinic Note or B) Urology Clinic Procedure |
Two members advocated for all SMD to have Surgical Note available to them to accommodate if a 'proceduralist' ends up doing a surgery in an emergency. A vote was done and the choice was made to restrict surgical notes to those SMD's who are licensed to perform surgeries. As always, individual health systems can ask for codes individually.
The choice to use LOINC's definition of Surgical Note and Procedure Note was not voted on. No concerns were voiced.
We need to add Podiatrists to list of surgeons.
For the order of the term for
Operative Note: 'B' was preferred
Procedure Note: 'B' was preferred
For the Concept Tables:
DS: 5
NS: 5
ML:5
MB (by email):5
IBek:5
Dl: 5
Explanation paragraph:
Most surgeries and most procedures: 100% of clinicians would agree on their classifications – you know it when you see it.
Surgeries involve more ‘manipulation of tissues’ than procedures, but there is a classification grey area in small surgeries and large procedures.
The document reader is not too concerned about the classification in this grey area. When looking for a document, they are looking for a specific event in which the patient's body was changed by surgery or investigated. They would like to look by the name of the process: "Colonoscopy", "Total hip replacement", "Bowel Resection". But that isn't a classification system. All we can offer is SMD and Type of Service. Since each patient doesn't get many surgeries/procedures from a single discipline, this is enough to narrow their search to a couple of documents. Document titles (free text) can do the rest. E.g., Search all Orthopedic Surgeries to find all the joint replacements you might find some joint injections. If not, search all Orthopedic procedures to find the joint injections.
Possible solution: build the Ontology with ToS = "Procedure" for all SMD’s* and only give the surgical SMD's a second option: ToS = Operative Report. Non-surgical SMD's only have the one ToS available to them, so there's no classification choice to get wrong there. The only place a real decision, and therefore a real grey area, exists is within the surgical SMD's, where the clinician can file an event as either Operative Report or Procedure as they see fit – Urology can call a vasectomy a Procedure even though Urology is a surgical SMD, which saves the data somewhat rather than forcing it into an ill-fitting Operative Report. We can leave that grey area alone: we trust the surgeon to make a reasonable call on their own case, and it doesn't cost us anything if two surgeons don't call it the same way, because SMD has already narrowed the search to a couple of documents regardless of which ToS they picked. We make general definitions for these ToS that aren't expected to produce 100% uniformity between clinical systems, or even within one – we accept 90%, because the reader just needs the thoughtfulness to check both ToS under a surgical SMD when they're used to seeing only one.
Editorial guidance:
Within surgical SMD's, Type of Service may be coded as either Operative Report or Procedure, at the coding clinician’s or health system’s discretion. Latitude is given where health systems — within themselves or between each other — do not agree on which of the two applies to a given event. Perfectly consistent classification between Procedure and Surgery, within or between systems, is not required for the ontology to function.