...
The openEHR Reference Model defines 6 kinds of Entry. Five of these are found in the openEHR EHR Information Model, and are illustrated below.
|
...
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.
|
|
...
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. |
| ||
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. |
|
|
Some basic Entry examples
...
Clinical Statement | Entry type | Example archetype | Comments |
simple measurement | Observation | Body mass index | The simplest 'point' measurements are still situated in time: there is always at least one 'event' or time-point. The openEHR model guarantees that the event-time information in single-point measurements is the same as for mult-sample measurements. |
time-series measurement | Observation | Blood pressure measurement | Many phenomena have the potential form of a series of samples in time |
difference over time | Observation | The History part of the model accommodates changes over time. | |
maxima, minima, rolling averages etc | Observation | The 'math function' attribute in the INTERVAL_EVENT class accommodates all kinds of time-based averages and finite duration states. | |
diagnosis | Evaluation | Times of some events may be mentioned, but the structure of the Entry is not the time-history of an observed phenomenon, but a report or summary, often of several phenomena, supporting a conclusion, which is the point of the Entry. | |
adverse reaction | Evaluation | Adverse reaction assessment is an assessment of condition or propensity of the patient to react to particular substances. |
...
Clinical Statement | Entry type | Example archetype | Comments |
Physician: | Observation | There will be an observation since it is a real-world phenomenon that has been observed e.g. by listening. There seems to be an element of 'inference' about it; this is the clinician's assessment of the heart sounds heard to be leaking of blood through the mitral valve of the left side of the heart. | |
| Evaluation | A diagnosis of mitral valve disease may be made; this will usually describe the severity, indicate what studies were done to establish the nature of the disease etc. This is not the same statement as any of the original observations, but would normally summarise them. | |
Patient: | Observation | Anything interesting the patient says may be recorded in the story, depending on the clinician and system. | |
| Evaluation | The clinician may or may not record a 'story'; if his assessment is that the patient is indeed diabetic, he would normally record a diagnosis; this has the same status as any other diagnosis recorded by a clinical professional. | |
Allied health professional: | Observation | Facts about the patient's capabilities in living independently are recorded as Observation(s), and gathered according to a protocol, such as a questionnaire, functional test by occupational therapist etc. How good the information is may depend on the protocol, but in all cases, the result is an observation of various phenomenon in time. | |
| Evaluation | An assessment will be made about the subject based on all the information gathered; some of the evidence might lead to the establishment of a problem of incontinence. |
...