ACTIONs, OBSERVATIONs and procedures
etienne at saliez.be
Wed Sep 2 15:33:05 EDT 2015
In my view when you get any Observation about the patient, just take it and
store in the record.
The concept of action is only necessary when some activity is planned and
ordered to be done in the next future.
On Wednesday 02 Sep 2015 10:56:17 Ian McNicoll wrote:
> Hi David,
> In theory you are correct but in many clinical records the date of the
> observation acts as a sufficient proxy for activity being performed.
> Where we do use actions is where we need to track the workflow of the
> procedure though there is not always a direct correlation between the
> procedure tracked and the observation.
> As an example a blood pressure will often be taken as part of a vital signs
> measurement. Ie the requested and tracked procedure is "perform vital signs
> measurement' every 4 hrs".
> I would use a single procedure action archetype to track the 'vital signs
> process' in the same composition as the individual observations.
> On Wed, 2 Sep 2015 at 10:23, David Moner <damoca at gmail.com> wrote:
> > Hello,
> > I have just had an interesting conversation with Diego during a coffee
> > break, and several doubts arose around the representation of procedures.
> > At the CKM we have an ACTION archetype to represent any type of
> > procedures. It is described as "A clinical activity carried out for
> > screening, investigative, diagnostic, curative, therapeutic, evaluative or
> > palliative purposes". So far, so good.
> > Now the doubt is about what happens when the procedure is something simple
> > and non-invasive that just generates an OBSERVATION. For example, a
> > temperature taking. Should we always have the ACTION.Procedure instance
> > generated together with the OBSERVATION.Temperature? Or do we just need to
> > record the procedure "temperature taking" as part of the protocol of the
> > OBSERVATION?
> > If the answer is to have both archetype instances, then probably most
> > OBSERVATIONs will allways have an ACTION linked to it. If the answer is
> > that in some cases we only need to record the OBSERVATION with a protocol,
> > then we are creating a division of all the universe of procedures, as
> > typically defined in terminologies such as SNOMED CT.
> > Thoughts?
> > --
> > David Moner Cano
> > Grupo de Informática Biomédica - IBIME
> > Instituto ITACA
> > http://www.ibime.upv.es
> > http://www.linkedin.com/in/davidmoner
> > Universidad Politécnica de Valencia (UPV)
> > Camino de Vera, s/n, Edificio G-8, Acceso B, 3ª planta
> > Valencia – 46022 (España)
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> > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.o
> > rg
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