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In the openEHR reference model a 'composition' or document contains one or more organising 'sections' - which themselves contain 'entries'. The ENTRY class of the openEHR reference model contains the information - the blood pressure, the assessment, the diagnosis, the medication order. Importantly, 'entries' can be interpreted independent of the composition or the section within which they are located - this is a key principle of the openEHR methodology and is very important for automatic processing of EHR data.
ENTRY, which is an abstract type (and does not exist in openEHR compatible data) has 4 concrete subtypes:
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#1.
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OBSERVATION
Observations are the 'uninterpreted' or raw information - ie the clinical observations or 'the evidence' - which includes anything reported by the patient as a symptom, event or concern; examination findings; and measurements/test results.
Thus an OBSERVATION is used when the information is derived from a direct observation, measurement, or experience of the patient or data subject.
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