HOW TO USE THE UROLOGY SNOMED MORBIDITY AUDIT AND LOGBOOK TOOL (MALT)

Transcription

1 HOW TO USE THE UROLOGY SNOMED MORBIDITY AUDIT AND LOGBOOK TOOL (MALT) OPEN MALT THROUGH SURGEONS.ORG Make sure you re using the correct logbook if you re doing a nonurology rotation in nset 1 CLICK ADD NEW CASE AND ENTER THE CASE DETAILS eg. Name, DOB, Supervisor etc SEARCH FOR THE TERM WHICH DESCRIBES THE PROCEDURE YOU RE RECORDING Make sure you only select terms which appear in bold COMPLETE THE PROCEDURE DETAILS If prompted, make sure you enter Further Information about the procedure from the dropdown list You can record more than one procedure under each case by clicking Save then searching for another procedure before you click Mark as completed If you can t find a term in bold to describe the procedure you ve performed, look at the UROLOGY SNOMED MALT HANDBOOK for trouble shooting. Non-bolded terms won t count towards your procedure totals DETAILED INFORMATION ON THE FOLLOWING PAGES

2 UROLOGY SNOMED MALT HANDBOOK The RACS Morbidity Audit and Logbook Tool (MALT) for Urology uses procedure terms from SNOMED, an internationally standardised system of medical nomenclature. Please read the instructions below to ensure you are using the logbook correctly. How to access the Urology MALT The MALT is accessed by logging on to the RACS website and following the links below: RACS portfolio > My Audits > Morbidity Audit and Logbook Tool (MALT). Please note, if you are doing a general surgery term in your nset1 year, you should be using a separate general surgery MALT. If you are doing a term with both general surgery and urology exposure, you should be using two separate logbooks. Please contact the MALT helpdesk at malt@surgeons.org if you are unable to access the correct logbook. How to enter a procedure Click + New Case to add a case to your MALT. Step 1 Under Case Details: Minimum Dataset enter demographic data such as name, DOB, supervisor etc. Step 2 Under the Operative Procedures tab, type the name of the procedure into the search box. Once you start typing, a list of SNOMED terms matching that procedure will appear beneath the search box. SNOMED includes thousands of terms for urological procedures. When using MALT, it is possible to select any SNOMED term to describe the procedure you are recording. However, so that logbooks are standardised, only some of these terms are approved by the Board of Urology these are known as Board Reporting Terms. When searching for a procedure, Board Reporting Terms will appear in bold and will float to the top of the list. Select the Board Reporting Term which describes (or is substantially similar to) the procedure you wish to record. If a bold term is available, do not select a term which is not in bold, even if it is a more accurate description of the procedure. If you select a procedure which isn t a Board Reporting Term, it will not count towards your procedure totals and will not appear on your Logbook Summary Report at the end of your rotation If you can t find the procedure you are looking for, check the list of Board Reporting Terms on the USANZ website to see if a Board Reporting Term exists for the procedure. If there is no Board Reporting Term for the procedure, you can select a term from the list which isn t

3 in bold, to record the procedure for your records. This procedure will not appear on your Logbook Summary Report at the end of your term. In the example below, Partial orchidectomy and Total orchidectomy are the Board Reporting Terms you can use to record an orchidectomy. Step 3 Under Procedure Details select your level of supervision from the drop-down menu. Primary Surgeon the registrar undertakes all or nearly all of each and every step of the surgical procedure Secondary Surgeon the registrar undertakes a significant proportion of the procedure (usually greater than 50%) Assistant Surgeon the registrar is scrubbed and assists in the procedure and may undertake some aspects of the surgical dissection which may include opening and closing of the primary wound. In the case of endoscopic procedures, the registrar may typically prepare the patient, introduce the endoscope, and may perform minor parts of the major descriptor of said procedure. Step 4 Some procedures will require you to add more information about the procedure from the Further Information drop down box.

4 In the example below, after selecting Total orchidectomy, you are prompted to add further information about the procedure. Step 5 Click Save to save the selected procedure to the case. Optional After saving the procedure, additional procedures can be added to the same case by repeating Steps 2 to 4. For example, Total cystectomy, Construction of ileal conduit, and Pelvic lymphadenectomy can be added as three separate procedures in the same case. Step 6 Click Mark as Complete to complete the case A few clarifications The following terms can be a bit confusing: Cannulation of ureter most simple procedures requiring ureteric cannulation (eg. retrograde pyelogram, ureteric stent, ureteric washings) are to be recorded under the term

5 Cannulation of ureter. You will then be prompted to complete Further information about the procedure to specify exactly what was done. Total nephrectomy/cystectomy/orchidectomy/urethrectomy In clinical practice we commonly use the terms radical or simple (eg. radical nephrectomy, simple nephrectomy) to describe complete removal of an organ. However, the aim of the MALT is to record acquisition of an operative skill set. In urology, radical and simple removal of an organ usually involves a substantially similar set of operative skills. Hence these terms are group together under the term total (eg. total nephrectomy can be used to record either a radical nephrectomy or a simple nephrectomy). You will often be prompted for Further information when you use one of these terms. After saving the procedure you can record a free text comment by clicking Add Comment. This space can be used to record further details of the procedure if the Board Reporting Term doesn t fully capture the nature of the procedure. A laparotomy for renal trauma is recorded as Exploration of kidney with further information 1. With preservation of kidney or 2. with trauma nephrectomy. There is crossover between the terms Exploration of scrotum, Surgical reduction of torsion of testis with fixation of contralateral testis, and Orchidepexy. For clarity, Exploration of scrotum refers to an scrotal exploration, usually performed acutely to exclude torsion. Surgical reduction of torsion of testis with fixation of contralateral testis refers to fixation of testis performed to prevent torsion. If you perform an acute scrotal exploration and bilateral fixation you can record both procedures in the case. Orchidopexy refers to an elective orchidopexy performed for an undescended or retractile testis Reimplantation of ureter refers to both paediatric and adult reimplantation (+/- Boari flap or Psoas hitch). Use the further information drop-down box to distinguish between paediatric and adult reimaplantations. It isn t mandatory to record Flexible cystoscopies, but there is a term for Flexible cystoscopy if you do want to record them.