Dear openEHR community,
I am a RN and fairly new to openEHR and would appreciate the community’s input on use of 2 archetypes: exclusion statement and absence of information.
What is the best approach to handle missing clinical data? Absence of information archetype is in my understanding used as a temporary statement (when information is not available/when we didn’t ask the patient/ when the patient has not told us) and exclusion statements are used for clinically proven absences (e. g. patient does not have diabetes 2). So when we model e.g. patient history including “No past surgeries/vaccinations/diagnosis XYZ/…” should we use an exclusion statement each time? Additionally, should we use absence of information archetype each time we want to record missing data or is using “unknown” in the value set (e.g. unknown if patient is on medication) “good enough”?
Would love some guidelines/examples from the community on best practices when to use these two archetypes.
Happy to have joined this community!
Kind regards,
Ana
2 Likes
Hi Ana and welcome,
The answer to your question very much depends on the context it is being asked.
The Global Exclusion, Specific exclusion and Absence of information archetypes are very much intended as authoritative statements, so would appear on an Problem list as a Global statement ‘ no significant problems’, or Absence ‘No information, patient in a coma’ or as a rule-out diagnosis Specific exclusion e.g ‘ Meningitis excluded’.
However, much more common are what we tend to call ‘questionnaire’ patterns, generally used in the early stages of gathering information, or as a kind of ‘checklist’. This is where you find questions like ‘Is there any significant past history?’ or Diabetes Mellitus? with answers like Yes/No/Unknown are normal.
An answer of yes is unlikely to result in Diabetes being added directly to the patient’s problem list. Much more likely is that a more senior member of staff adds that as a formal Problem diagnosis if ‘Y’ and ignores the No/Unknown.
So, I suspect that in most circumstances you describe, you probably want to use the ‘screening questionnaire’ archetypes. e.g https://ckm.openehr.org/ckm/archetypes/1013.1.4442
Hope that helps.
2 Likes