Synoptic operative report templates enable clinicians to capture and display succinct clinical information in a standardized and logical manner. Synoptic operative report templates also provide the optimum goal of enriching personalized health information of a given patient at the point of care so as to support the exchange of clinical information across the continuum of multiple healthcare providers. However, most of the available synoptic operative report templates in many clinical settings do not incorporate interoperable standards in their design and implementation.
This project implemented a template (i.e., eSOR-SCI) that uses interoperable standards for its design and implementation. The implementation of the eSOR-SCI template was completed in September 2012. It was designed to be conformant with the HL7 Clinical Document Architecture (CDA) Implementation Guide for the Operative Note and to represent clinical activity using the HL7 Clinical Statement pattern encoded with Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) terminology.
Location: Halifax, Nova Scotia, Canada