Including past consult records in pdf form

Clinical
1

Hi,
I have a need to include past records available in pdf form to the EHR of patients. The obvious choice would be to use the media file cluster for this.

This works well for lab/imaging diagnostic reports as I am able to create a template as below

  • Lab report - openEHR-EHR-COMPOSITION.report.v1 contains openEHR-EHR-OBSERVATION.laboratory_test_result.v1 contains openEHR-EHR-CLUSTER.media_file.v1
  • Imaging report - openEHR-EHR-COMPOSITION.report.v1 contains openEHR-EHR-OBSERVATION.imaging_exam_result.v1 contains openEHR-EHR-CLUSTER.media_file.v1

However for records such as OP consult & discharge summary, I am not sure what is the best practice. Since media file is a cluster, it cannot directly be included in the encounter composition. What observation/evaluation archetype is best suited for this use case.

If there are any better approaches, please advise.

regards
Dileep

2

Hi Dileep,

We had this issue in London, where some stored files dod not have a natural home in terms of other Entries and created a wrapper Free Attachment ADMIN_ENTRY archetype, which we thought we might need to include some local legacy app metadata (hence the name and type elements) but did not actually use them in production.

If this is a wider need, perhaps we could jointly work on a CKM proposal? Perhaps it is just a very simple ADMIN_ENTRY wrapper with a slot?

openEHR-EHR-ADMIN_ENTRY.free_attachment_ol.v0 (1).adl (2.3 KB)

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3

Hi Ian,
That should work. An additional node to indicate the current status of the document(current, superseded etc.) could be added.

If you did not use it in your London use case, how did you manage it?

I feel that such an archetype has a wider use in actual implementation as most of the projects will have such legacy data to deal with and openEHR does not seem to have a standard way of templating them. I am happy to join you to work on a CKM proposal. Let me know what to do next.

regards

4

Sorry we did use the archetype but constrained out the name and type elements.

I think status might be better added to the media resource archetype but up for discussion.

5

Shall we propose this for the CKM? I think it will be useful to others also

Status does make more sense being part of the media file cluster :slightly_smiling_face:

regards

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