Hi all,
Considering these questions:
1- (asking patient) : Have you noticed any swelling of your salivary glands?
2- Inspection of salivary glands (Actually for this one, based on a suggestion from Ian I intend to create Cluster: Inspection- Salivary glands)
Should one just create one Observation or Cluster to use it for both cases or do you suggest another way of modeling these two concepts?
As you may notice, the first question is info. that the clinician receive from the patient by just listening and in the second one we will have a real physical inspection.
I have the same situation for Asking about disease history and observation and evaluation. e.g:
1- Do you have HIV?
2- one observation that may lead to a evaluation of HIV
In my view, any history of diseases has been actually an Evaluation at its time! but what if for now, just this info like the name of the disease is important for me to keep track of?
It is tempting to see information being different if it is entered at the time or at a later date. The problem is that if a person has diabetes and it was diagnosed in 2002 then I would argue that if the diagnosis and date of onset is entered at the time it is identical from an informational perspective to the same information being entered 5 years later when the site became computerised in 2007.
In the openEHR architecture we have argued that this is the same information entered at different times. Clearly the person at the time, or 5 years later, may have access to different information that may or may not have been available at the time of diagnosis. Again, this could be more or less accurate either earlier or at a later date. Sometimes it is only the passage of time that makes the actual situation clearer (or less clear as the case may be).
So, while you may report that the patient said they have diabetes – it is usual practice if a person presents and clearly has a disease for this to be entered as a statement of the same ‘weight’ having considered the behaviour of the person and other factors.
I hope you will see why problem and diagnoses are always appropriate to enter as an evaluation using the archetype. These may be moved to a problem list or past history or wherever, but have the same meaning.
Definition of Patient State and the 4 Clinical Entry Archetypes
Entry DCM/Archetype
|
Definition
|
| - |
Patient System | The ensemble (states and processes) of the constituting parts of the body, the body as a whole and its social and other environment of a person that is the recipient of healthcare delivery. |
Observation | An archetype that defines what needs to be documented about a specific state in the patient system at a point in time using the faculties of seeing, hearing, tasting, touching, smelling, or via a medical device. |
Evaluation | An archetype that defines what needs to be documented about a process in the patient system using observations, expertise and knowledge. |
Instruction | An archetype that defines what needs to be documented about intended actions to change the state or process in the patient system. |
Action | An archetype that defines what needs to be documented about events that change (or could change) states or processes in the Patient System |