The definition of summary data is unclear regarding quite what a summary is expected to be


The definition of HISTORY.summary is "optional summary data expressing e.g. text or image which summarises entire history." I don't think this definition is sufficiently broad, and I always get unaccountably uncomfortable when people ignore the restrictions imposed by definitions.

Ian says: I think I probably have a somewhat more liberal interpretaion of 'summarisation' , which would include analysis or interpretation of the data, to include 'tissue/lab/x-ray diagnosis' but short of clinical diagnosis.

I found the recent JAMIA paper on the"AORTIS model" extremely helpful in clarifying my thinking on this. "Our model identifies five distinct stages of clinical summarization: (1) Aggregation, (2) Organization, (3) Reduction and/or Transformation, (4) Interpretation and (5) Synthesis In my view everything below synthesis belongs in an Observation, since it relates to the observation or test itself and not to the patient as a whole. This get a little hazier in anatomical pathology, particularly haematological disorders, but even then there is a fairly clear distinction between a tissue diagnosis, which is partof a lab report and an actual diagnosis.

Ian's view would be fine, but this suggests that the definition needs clarification. I suggest:

"optional summary data that aggregates, organizes, reduces and transforms the event series. This may be a text or image that presents a graphical presentation, or some data that assists with the interpretation of the data"




Grahame Grieve




Affects versions