ACTIONs, OBSERVATIONs and procedures
Dr Sam Heard
sam.heard at openehrfoundation.org
Thu Sep 3 04:02:18 EDT 2015
The sick note signing etc can be a set of actions if needed, or the composition can be in a variety of states using versioning. Instructions allow workflows to be traced formerly in the health record rather than in an arbitrary way specific to a particular software.
From: "Vebjørn Arntzen" <varntzen at ous-hf.no>
Sent: 3/09/2015 4:47 PM
To: "'For openEHR clinical discussions'" <openehr-clinical at lists.openehr.org>
Subject: SV: ACTIONs, OBSERVATIONs and procedures
What about the need to track a workflow of a kind – e.g. something we are dealing with right now: A sick note (medical certificate to inform employer and authorities for social benefits) is needed to be made in the EHR. The form will change status – from started on, filled in, signed, maybe co-signed, sent (the careflow steps are not fully identified). Is this relevant for an ACTION, or is it “something else”? It’s not really medical information, but still related to the patient.
Oslo university hospital, Norway
Fra: openEHR-clinical [mailto:openehr-clinical-bounces at lists.openehr.org] På vegne av pazospablo at hotmail.com
Sendt: 3. september 2015 00:45
Til: etienne at saliez.be; openehr-clinical at lists.openehr.org
Emne: Re: ACTIONs, OBSERVATIONs and procedures
That is not 100% correct, actions can be recorded without any related instruction/activity.
I agree with Ian, action recording makes sense when there is some tracking going on, if just the measures are needed (from the clinical point of view) no actions will be recorded, just obs.
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------ Original message------
From: Etienne Saliez
Date: Wed, Sep 2, 2015 16:33
To: openehr-clinical at lists.openehr.org;
Subject:Re: ACTIONs, OBSERVATIONs and procedures
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.Etienne SaliezOn 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.> > Ian> > On Wed, 2 Sep 2015 at 10:23, David Moner 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)> > _______________________________________________> > openEHR-clinical mailing list> > openEHR-clinical at lists.openehr.org> > > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.o> > rg_______________________________________________openEHR-clinical mailing listopenEHR-clinical at lists.openehr.orghttp://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
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