Gerard Freriks wrote: > The EHR is about recording observed facts. > > One of those facts is the "use of substances". > This means one has to document: > - What > - What for > - How > - How much > - When > - Prescribed by whom, when, where > - Dispensed by whom, when, where > - Administered by whom, when, where > - Used when > - ... > > Irrespective of a regular drug, herbal tea, food additive, smog, self > medicated, prescribed, or taken by an involuntary action > one always want to record the same things. > Isn't it? > > So why not a generic Archetypes: "Observation: Substance Use" that model above is pretty close to this: http://oceaninformatics.biz/archetypes/openEHR-EHR-OBSERVATION.substance_use.v1.html but I guess the reality is that tobacco, alcohol and a few others deserve more detailed modelling, since they are of major importance and have their own specific questions attached.
Also, there is a difference between Observations of substance use (or any other activity of the patient, e.g. exercise) and therapeutic medication (including of herbal tea or suchlike). The latter is modelled as Instruction and the administration and other actions that occur (e.g. suspend, cancel etc) are modelled as Actions (a kind of Observation). The model and therefore the archetypes differentiate between consumed substances, and intentionally therapeutic interventions, even though at the physical level both may be describable as a person drink a glass of fluid.... - thomas beale
