Dear gerard, If i want to collect the ff simple data for claims, will 13606 suffice?
Patient id Last name Given name Birthday Sex Provider id Facility id Icd10 diagnosis main Icd10 diagnosis cooccuring Cpt code main Cpt code others Fulltext diagnosis Fulltext procedures Timestamp Alvin Sent from my iPad On Dec 11, 2011, at 17:22, openehr-clinical-request at openehr.org wrote: > Send openEHR-clinical mailing list submissions to > openehr-clinical at openehr.org > > To subscribe or unsubscribe via the World Wide Web, visit > http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical > or, via email, send a message with subject or body 'help' to > openehr-clinical-request at openehr.org > > You can reach the person managing the list at > openehr-clinical-owner at openehr.org > > When replying, please edit your Subject line so it is more specific > than "Re: Contents of openEHR-clinical digest..." > > > Today's Topics: > > 1. Re: Revision of Instructions - clinical implications (Jussara) > > > ---------------------------------------------------------------------- > > Message: 1 > Date: Sun, 11 Dec 2011 07:21:41 -0200 > From: Jussara <jussara.macedo at gmail.com> > Subject: Re: Revision of Instructions - clinical implications > To: For openEHR clinical discussions <openehr-clinical at openehr.org> > Cc: For openEHR clinical discussions <openehr-clinical at openehr.org> > Message-ID: <FDF297AC-52E7-4424-8375-CBCC2A2D8D06 at gmail.com> > Content-Type: text/plain; charset="us-ascii" > > Hi, > Think it's easy to distinguish one from another if you think on a paper > record. Instructions and actions are separated there. Instructions are the > orders ( instructions) recorded when finishing patient 's evaluation and > actions are recorded when they were either performed, or suspended, or > postponed, or even not done. I.e actions follow instructions in the workflow. > > Jussara > > Sent from my iPad > > On 11/12/2011, at 06:47, Gerard Freriks <gfrer at luna.nl> wrote: > >> Dear Jagannathan, >> >> I see the big confusion developing. >> There is HL7 thinking and 13606 thinking. (and openEHR thinking) >> >> In HL7 'the act' of documentation is modeled as an Act with a specific mood >> code. >> In 13606 'the act' of documentation is about either an Observation >> archetype, an Evaluation archetype, an Instruction archetype , an Action >> archetypeor any other constructs we might need (e.g. Administrative, etc). >> In HL7 there were (are?) too loose definition so one time (2006) the >> question: Is a Patient Record an Entity or an Act? created a huge debate and >> confusion. >> >> In 13606-circles these specialised Entry-Classes are defined in an other way >> than in openEHR. >> In openEHR their Reference Mode constrains 'hardcoded' the specialised >> classes; Observation, Evaluation, Instruction and Action. >> In 13606-circles we feel that our Reference Model should stay as generic as >> possible. The Entry Class is sufficient. >> We deal with these specialisations of the Entry Class using semantic >> patterns that constrain the Entry Class and depending classes via >> archetyping to reflect the specialisation >> >> In order to understand the picture it is essential to observe that when we >> document we can perceive states, using our senses or machines, phenomena at >> points in time. Phenomena that are the result of ongoing processes inside >> the patient system, documented using the Observation archetype. >> All the observed phenomena (observed states) give rise to inferences about >> the process and that are documented using the Evaluation archetype. We can >> not observe processes inside the patient system. >> The inferences together with the existing knowledge and experience gives >> rise to instructions/orders to do something to influence the processes >> inside the patient system or collect more Observations on states. These are >> documented using the Instruction archetype. >> As acts of God or as the result of Instructions deeds are done that either >> influence the observable states or influence the processes in the patient >> system, using the Action archetype. In between instructions and actions >> there can be protocols or clinical pathways or workflow machines, or case >> management tools. >> >> Each of the four defined archetypes (for the Observation, Evaluation, >> Instruction or Action) carry their own state model. Some are more complex >> than others. (e.g. the state model or the Observation can be simple. That of >> the Action is more complex. These state models can influence each other >> sometimes. E.g. when all instructions have been performed by means of the >> execution of actions (and updating the state model of the actions) the >> state model of the corresponding instruction needs to be updated to reflect >> this.) >> >> A strict adherence to these definitions leads to the consequence that what >> is modeled in openEHR as one Observation, in EN13606-circles will be modeled >> as an Action archetype (documenting the execution of an >> observation/measurement such as Blood Pressure Measurement) and a 'coupled' >> Observation archetype where the result of the measurement is documented. The >> Action archetype will document the method/protocol, etc. used in that Action >> archetype to measure something. >> >> Each Entry Class archetype defines one Clinical Statement/Detailed Clinical >> Model (DCM)/ Clinical Information Model (CIM), using constraints. >> Each Entry archetype defines only one topic, one measurement, one diagnosis, >> and all its semantic context as one semantic atomic construct. >> This means that something like the Blood Pressure measurement actually is a >> Panel, an ad-hoc assembly of two or more semantic atomic clinical statements >> (archetypes Entry Class). >> This means that in EN13606 thinking the Blood Pressure Measurement is >> defined by constraining the Section Class to 'hold' at least two Entry >> classes. One for the systolic and one for the Diastolic Action/Observation. >> In this way all Panels will be modeled as sections in EN13606. >> >> Each update in any state model, each update of data or information >> documented, and as specified using an archetype, will have to result in a >> new version and properly documented to make the complete audit trail >> possible. >> >> The thinking as developed in EN13606-circles will be provided to CEN/ISO >> (and CIMI) as input for standardisation. >> For more info have a look at http://www.En13606.org and at the EN13606 WIKI >> at that site. >> >> For the figure about the Patient system and the Entry classes see: >> http://en13606.webs.upv.es/wiki/index.php?title=File:GF_Archetype_and_Patient_System.png >> >> >> Definition >> >> Patient System >> The ensemble of the constituting processes and 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. >> Entry Class >> A Class in the EN13606 EHR-com model that can be constrained to generate >> clinical relevant statements about an entity for documentation. >> Observation >> An Entry Class archetype that defines by constraining the Entry Class of >> EN13606-1 >> what can be documented about a specific observed state of a process in the >> Patient System at a point in time using the faculties of seeing, hearing, >> tasting, touching, smelling, or directly via a medical device or service. >> Evaluation >> An Entry Class archetype that defines by constraining the Entry Class of >> EN13606-1 >> what can be documented about an inferred process in the patient system using >> observations, expertise and knowledge, >> or about plans with, >> or risk assessments about, the Patient system. >> Instruction >> An Entry Class archetype that defines by constraining the Entry Class of >> EN13606-1 >> what can be documented about the intended actions with the aim to change the >> state or process in the Patient System. >> Action >> An Entry Class archetype that defines by constraining the Entry Class of >> EN13606-1 >> what can be documented about events that changed (or could change) states or >> processes in the Patient System. >> >> >> >> >> Gerard Freriks >> +31 620347088 >> gfrer at luna.nl >> >> >> Gerard Freriks >> >> EN13606 Association >> p/a Huigsloterdijk 378 >> 2158 LR Buitenkaag >> The Netherlands >> >> M: +31 620347088 >> E: gerard.freriks at EN13606.org >> W: http:www.en13606.org >> >> On 11 dec. 2011, at 07:20, S Jagannathan wrote: >> >>> Agreed,that is exactly how I understood it. So strictly speaking the >>> instruction is an action preceding another action!! >>> >>> Sent from my iPod >> >> >> >> >> Gerard Freriks >> +31 620347088 >> gfrer at luna.nl >> >> >> >> >> _______________________________________________ >> openEHR-clinical mailing list >> openEHR-clinical at openehr.org >> http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical > -------------- next part -------------- > An HTML attachment was scrubbed... > URL: > http://lists.chime.ucl.ac.uk/mailman/private/openehr-clinical/attachments/20111211/5aaac118/attachment.html > > > ------------------------------ > > _______________________________________________ > openEHR-clinical mailing list > openEHR-clinical at openehr.org > http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical > > End of openEHR-clinical Digest, Vol 62, Issue 10 > ************************************************
