Recording absence of (clinical) information

Thomas Beale thomas.beale at
Tue Sep 17 04:15:10 EDT 2013

On 15/07/2013 10:17, Koray Atalag wrote:
> Hi Gerard, thanks for your response.
> I agree that a simple Boolean data type is not suitable -- that's why 
> we used a TEXT item (called Presence) with Present, Absent, Unknown 
> values. The reasons why information is not known can further be 
> specified (I reckon with great diversity) if required which we chose 
> not to implement. We have a tri-state checkbox that corresponds to the 
> three values of the Presence item and on GUI when first initialised 
> the checkbox is clear (e.g. does not have any of the three states). 
> User can select any of the three values and it is also possible to 
> 'clear' the control -- which means that item has never been captured. 
> I think (just my opinion) this is a pattern which can be applied to a 
> wider range of clinical findings. I won't dare to say it would apply 
> to all ENTRY types but probably a majority of OBSERVATION and perhaps 
> EVALUATION type data items.
> To further elaborate on Ian's comment which just came as I am typing 
> this I think there are two things here:
> (1) generic that can better be represented consistently at RM level;
> (2) that can be quite specific as per clinical context and requirements.
> Along the lines of Ian's proposal I think the current method of 
> representing negation/exclusion and absence/why information is not 
> available with two different archetypes might be transformed into a 
> pattern like:
> 1)RM Attribute to denote/flag/draw attention at ENTRY class level of 
> CODED_TEXT type which has the three enumerations as I described above. 
> I don't think a fourth one indicating "Null" will be required as this 
> would be implicit by its appearance in instance data. Obviously this 
> is related to both Negation/Exclusion and Absence -- but this is the point

Hi Koray,

how could there be a single presence / absence / unknown flag on an 
openEHR ENTRY? An ENTRY can contain numerous data items...

- thomas
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