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RM Class | Attribute | Description | Lab request/referral | Lab result/report | Encounter | Consultant report | |
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CONTRIBUTION | audit. | Time compositionCOMPOSITION(s) were | Request received locally | Report received locally | Record received locally | Report received locally | |
COMPOSITION | Commit time ORIGINAL | commit_audit. | Time composition is saved | Request sent | Report issued | Note recorded committed to EHR system | Report issued |
(Event related | context.start_time | The time (or start time) | Request created/recorded | Report created/recorded | Patient encounter begins | Report created/recorded (may relate | |
| EVENT CONTEXTcontext.End end_time | End time of the event or | Not usually recorded | Not usually recorded | End time of the | Not usually recorded unless at the | |
PARTICIPATION | Start time/End time time.lower, | The time that a person | Duration of other | Duration of other | Duration of other | Duration of other | |
ATTESTATION Time | time_committed | The time this COMPOSITION | Time of signing the request/referral or any part thereof | Time of clinician or | Time of signing the | Time of signing the encounter note | |
OBSERVATION | EVENTdata.Start time origin | The clinically relevant start time | N/A | Time the sample was | Time of the observation | Time of the observation | |
| data.events(n).time | The clinically relevant time of a given observation in a series. For 1 event, origin and event time usually the same. | N/A | = origin | Time of the observation | Time of the observation | |
ACTION | Time time | The time this action was completed | Time of the action | Time of the action | Time of this action | Time of this action | |
INSTRUCTION | expiry_time |
| Time this request/referral expires | Time this request/referral expires (as per original Instruction if Instruction is also required in the report (otherwise refer to the Instruction in the referral/request Composition). If the Instruction has been changed by the filler, then the changed Instruction may be included in the report, and its expiry time will be used). |
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RM Class | Attribute | Description | Lab request/referral & results/report | Medication Order | Encounter |
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ENTRY | workflow ID | Unique logical identifier for the running process instance, which may be executed in the real world or within a messaging environment, or within a workflow management system. | Usually the Placer ID (Filler ID may also be used) | Prescription number (if from an ordering system), or a Job number (if from a dispensing system). | Encounter ID |
Referral and Report content
- Referrer sends referral with INSTRUCTION + ACTION (on the request)
- Filler sends tracker INSTRUCTION + ACTION
- Filler sends report with OBSERVATION + ACTION
- +/- changed INSTRUCTION OR
- +/- original INSTRUCTION via "Citation" cluster archetype that contains the following 3 elements:
- Citation (DV_PARSABLE)
- URI to original data (DV_URI) - in this case EHR_URI to the original INSTRUCTION in the referral composition.
- Comment (DV_TEXT)
- Order tracker receives INSTRUCTION and ACTION. This covers the manual entry of the INSTRUCTION.
Change requests
- Change the 'workflow ID' ENTRY attribute definition in the openEHR IM specification.
- Add 'version ID' as part of the workflow ID in situations where the process/workflow has been modified???
The clinically relevant time of the observation