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The openEHR Reference Model defines 6 kinds of Entry. Five of these are found in the openEHR EHR Information Model, and are illustrated below.
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Detailed UML | - OBSERVATION - for recording information from the patient's world - anything measured by a clinician, a laboratory or by them, or reported by the patient as a symptom, event or concern
- EVALUATION - for recording opinions and summary statements (usually clinical), such as problems, diagnoses, risk assessments, goals etc that are generally based on Observation evidence
- INSTRUCTION - for recording orders, prescriptions, directives and any other requested interventions
- ACTION - for recording actions, which may be due to Instructions, e.g. drug administrations, procedures etc.
- ADMIN_ENTRY - for recording administrative events, e.g. admission, discharge, consent etc
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The types of information generated in the clinical process are qualitatively different; they have different relationships to time, to actors, and consequently have different structures. There have been various models of these over the years, from Lawrence Weed's POMR "SOAP" headings to more recent models such as the Danish G-EPJ. The openEHR model uses a similar set to some of these models. The exact types used in openEHR are based on an analysis of the process that creates health information. The following diagram illustrates the process metaphor and a more formal definition of the information categories it generates.
 Image Added | - observation: information created by an act of observation, measurement, questioning, or testing of the patient or related substance (tissue, urine etc), including by the patient himself (e.g. taking own blood glucose measurement), in short, the entire stream of information captured by the investigator, used to characterise the patient system;
- opinion: thoughts of the investigator about what the observations mean, and what to do about them, created during the evaluation activity, including all diagnoses, assessments, speculative plans, goals;
- instruction: opinion-based instructions sufficiently detailed so as to be directly executable by investigator agents (people or machines), in order to effect a desired intervention (including obtaining a sample for further investigation, as in a biopsy);
- action: a record of intervention actions that have occurred, due to instructions or otherwise;
- administrative event: a record of a business event occurring within the administrative context, such as admission, booking, referral, discharge etc.
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In the openEHR Entry model, two types are used for 'observations' and 'evaluations'. As with any general terms, these terms are overloaded, causing confusion for some people. In the openEHR model, these two types have a clear purpose. The Observation type is used to record any information derived from the world outside the clinician's head (or any other clinical reasoning device) - i.e. any kind of phenomemon or state of interest to the clinical investigator in the care of the patient. Accordingly, the design of the Observation type defines its data as a History-of-events structure, since all phenomena observed in the external world are situated in time, and in many cases, there are multiple samples to be recorded. In theory, such information should be repeatably observable using the same protocol and assuming a sufficient level of skill or training on the part of the observer.
In contrast, the Evaluation type is used for recording clinical thinking rather than events from the outside world. Consequently, it does not oblige a historical timing structure. This is not to say that 'time' is irrelevant to clinical thinking. Indeed, many typical clinical assessments include all manner of times, as shown by this diagnosis archetype. However, the times in such evaluations are not the primary recording instance of phenomenon or event time of events that may be referred to in the Evaluation, but instead are summarised times, dependent on the kind of assessment being recorded. It may be that no event time is recorded in an Evaluation, such as for the goal archetype, where the only time indicated is future proposed date of achievement. |  Image Added |
Thus the Observation type provides the structures for recording phenomena, including statements the patient may make, anything measured or sensed by the clinician, or via using a machine. The history structure provides a standardised way to include the event origin time, and offsets of each event in the series, if it is more than one. In addition, it provides 'state' and 'protocol' (the latter inherited from CARE_ENTRY) which allow the state of the patient (e.g. position, exertion level) and the method (e.g. pulse oximeter) to be recorded alongside the primary data (e.g. heartrate). The history structure of a typical observation is illustrated to the right. |  Image Added |
Some basic Entry examples
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