We need to record daily clinical notes during a clinical EPISODE in an INPATIENT context.
On one hand, we believe that openEHR-EHR-COMPOSITION.encounter.v1 could be used for this use case. The intended purpose does not appear to fall outside the scope of the archetype, and it is a validated and mature archetype.
On the other hand, openEHR-EHR-COMPOSITION.progress_note.v0 is currently in DRAFT status and lacks a SLOT extension to “other_context”, without which we would be unable to include the contextual data required for our implementation.
Our doubts start when reading the “Use” section of the archetype:
“…Progress notes are more typically used to record ongoing care notes by various providers participating in aspects of care during some kind of healthcare episode, as distinct from a one-off face-to-face meeting in a clinic which is typically recorded as a COMPOSITION.encounter…”
To sum up
Can COMPOSITION.encounter.v1 be used to record INPATIENT care events during an EPISODE?
Is COMPOSITION.progress_note.v0 primarily intended for nursing documentation? Is it more generally designed to record ongoing INPATIENT care events during an EPISODE?
I seem to recall that we had this conversation some time ago @heather.leslie and I think I remember your response, but I didn’t write it down. I should have.
Any implementation experience in a similar context, or any clarification regarding the intended scope of these archetypes that could help us make the right modelling choice, would be greatly appreciated.
Context picture below:
What would a clinical note contain:
The two options under discussion:
Multiple compositions (an instance for every clinical note) , would become a movie based on what happens in the episode.