Aniket Thanks for that. Thanks for your thoughts.
> There are finite orders in the Medical Terminology > which can be classifed according to the department and > coded. > Effort such as CPT(Common procedural terminology) can > be extended and continued to encompass all such > 'action specifications'. > Thus the medical record can be structured broadly into > a.Enquiry specifications(history) We call these observations (as per Rector) - the subject is the source. > b.Examination specifications(clinical examination) We also call these observations - the clinician is the source. It is quite difficult to separate these more conclusively - a patient may say they are constipated and have not used their bowels for 5 days - in a nursing home a care attendant might notice that the patient has not used their bowels for 5 days. These are no different except in source and we have found it helpful to use the same information component. > c.Action specifications which can be further divided > into > 1.Clinical actions(Temparature,Pulse,Blood Pressure > etc.) As we are only concerned with the record - we can record these as observations - but they can be the subject of an instruction. For these types (having their own archetype) the specification is not so important - but with medication and other complex instructions it becomes very helpful to reuse the instruction data. > 2.Laboratory actions(All lab orders) These are instructions > 3.Procedure actions(OT,Cath-lab) These are often complex records - but for us at present are an observation with the ability to accept an action specification. > 4.Medication actions. Administration is the same as procedure - but the medication order is an instruction. Cheers, Sam > Thus the terminology can be classified and coded. > Based on the Clinical experiences the frequency of > these 'Specifications'can be varied and we amy have a > more or less structured Medical record. > Furhtermore,based on the granularity of enquiry > specifications we may be able to classify the results. > CPGs can be incorporated in these. > Comments > ANIKET > > --- Sam Heard <sam.heard at bigpond.com> wrote: > > > > Dear All > > > > In developing an ontology for health record > > recordings - an archetype > > ontology - I have come to the idea that there is a > > great deal of utility in > > the idea of an 'action specification'. This is the > > part of an instruction > > that says what to do - not when (or under what > > conditions) to do it. > > > > Let me give you an example: > > > > A medication order is an instruction: > > > > medication=Amoxycillin: dose=250mg: route=IV: > > frequency=three times daily > > > > The action specification is: > > > > medication=Amoxycillin: dose=250mg: route=IV > > > > The when part is: > > > > frequency=three times daily > > > > OR A Pap test notification instruction might > > consist of: > > > > Action is Pap Test & send specimen to laboratory > > When is two years since last pap test OR 1/1/03 > > > > The important thing is that the 'action > > specification' can be reused in the > > EHR as a record of what was done. So a medication > > administration reuses the > > action specification of a medication order - and has > > a record of who > > administered it - likewise for the Pap test. > > > > There may be no need to do this at the information > > model level - perhaps > > leave it to the application. But there are some > > advantages - a consistent > > description of what is to be done and what was done > > using the same > > structure - guaranteed transformation from an > > instruction to recording an > > action. > > > > Comments? > > > > Cheers, Sam > > ____________________________________________ > > Dr Sam Heard > > Ocean Informatics, openEHR > > Co-Chair, EHR-SIG, HL7 > > Chair EHR IT-14-2, Standards Australia > > Hon. Senior Research Fellow, UCL, London > > > > 105 Rapid Creek Rd > > Rapid Creek NT 0810 > > > > Ph: +61 417 838 808 > > > > sam.heard at bigpond.com > > > > www.openEHR.org > > www.HL7.org > > __________________________________________ > > > > > > > > > > > > ____________________________________________ > > Dr Sam Heard > > Ocean Informatics, openEHR > > Co-Chair, EHR-SIG, HL7 > > Chair EHR IT-14-2, Standards Australia > > Hon. Senior Research Fellow, UCL, London > > > > 105 Rapid Creek Rd > > Rapid Creek NT 0810 > > > > Ph: +61 417 838 808 > > > > sam.heard at bigpond.com > > > > www.openEHR.org > > www.HL7.org > > __________________________________________ > > > > - > > If you have any questions about using this list, > > please send a message to d.lloyd at openehr.org > > > __________________________________________________ > Do you Yahoo!? > Yahoo! Mail Plus - Powerful. Affordable. Sign up now. > http://mailplus.yahoo.com - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
