Use Case Diagram

David Lambert has been booked for an outpatient reconstruction of his anterior cruciate ligament (ACL). He presents to the hospital on the appointed day and goes through the admission process. He checks into the outpatient surgery department and is assessed by a nurse there. She confirms the procedure to be done and obtains vital signs from him. This pre-operative nursing data is recorded in his EMR.

Before David is taken to the OR, the anaesthetist accesses his records and views his health profile. She also searches for and reviews the pre-operative physical exam report that was done by Dr. Black two weeks ago. She then assesses David herself, by taking a history and performing a physical exam. The anaesthetist records her findings in the EMR.

At the appropriate time, David is taken to the OR. Dr. Abram, the orthopaedic surgeon, accesses David’s records and reviews the report of the MRI along with his own notes from the outpatient visits. Familiar with the details of David’s case, Dr. Abram proceeds to do the ACL reconstruction. Afterwards, he creates an operative report that summarizes the procedure and saves it to the EMR. The OR nurse completes the nursing notes for the surgery and saves them in the EMR. The anaesthetist does the same, updating her anaesthesia record.

David is taken to the recovery room after the surgery. The nurses there care for him while he recovers from the anaesthesia. They record their observations and actions in the EMR.

Once ready, David is taken from the recovery room to the outpatient post-operative ward. Nurses there care for him as he continues to recover through the afternoon. Once he is sufficiently fit, David is discharged home with his wife, Linda. The nurses record their observations and actions in the EMR.

Procedure	Allergies
Medications	Past medical/surgical history
Vital signs

History	Past medical/surgical history
Pre-op physical exam	Orders
Intra-op findings	Post-op findings

Date	Surgeon
Assistant(s)	Procedure
History	Summary of operation
Post-op plan

Nurses	Date
OR times	Equipment

Physical exam	Medications
Interventions

History	Physical exam
Medications	Interventions
Discharge time

Health Service

This health service follows upon the orthopaedic consultation (see 6.1.3) and describes all the health service events taken during the patient visit at the urban tertiary care hospital outpatient orthopaedic clinic in the jurisdiction where the patient lives; he has been treated at the hospital in the past.

Each health service event takes place during a same period of time (e.g. without cut of time), in presence or not of involved client; the health service events can be grouped in a health service encounter.

General Info
Name	6.1.4 ACL Reconstruction Encoutner Diagram
Type	Use Case Diagram

1 Description of Health Service Encounter

Health Service