Protocol

All the CARE ENTRY classes in the openEHR EHR Reference Model have a protocol section. This includes the OBSERVATION, EVALUATION, ACTION and INSTRUCTION classes. The protocol section was added early in the design of openEHR based on research at the time demonstrating that computerisation meant that a lot of detail could be added to the documentation that could be of use in the future.

The protocol section of an ENTRY is used to record information that is not critical to but may add value to the interpretation of a measurement. This often includes information about the way something was measured such as the device or location of a measurement (when the measurement value is applied to the body - such as temperature). It is considered an application issue as to whether the protocol information is displayed or not, but it should be available if required.

Examples include:

  • The type of measurement device used to measure a temperature
  • The location and size of a blood pressure cuff
  • A web reference to pertinent information about a diagnosis

Information about the state of the patient at the time of measurement which will affect the interpretation of the reading is recorded in the State section of the OBSERVATION class.