Thomas, When we agree that the scope of OpenEHR is to document the professional opinions and the facts on which these are based then: > An instance of an Instruction documents roughly what might be in a > prescription
But it is semantically NEVER the same. It is the documentation of the process that lead to a prescription. It is NOT a prescription. Gerard -- <private> -- Gerard Freriks, arts Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252 544896 M: +31 654 792800 On 9-sep-2005, at 11:46, Thomas Beale wrote: >> The EHR is a document that documents. >> Then the EHR is the record of what happened. >> In that context it records that an order was given to dispense >> medication. >> But this is not the same as the medication order itself. >> > > In openEHR, we side-step all such problems and keep it simple. An > instance of an Instruction documents roughly what might be in a > prescription - the description of the drug or therapy(ies), the > administration timing, route, etc, procedure if relevant, and other > activities like monitoring, conditions for suspending etc. This is > enacted by human or computer workflow executors. Each thing they do > they record using an instance of Act or Instruction_act (new Entry > subtypes in openEHR). It does not have to be part of the data who > is being asked to enact it (but it can be - done with > particpations); they will be asked via some appropriate > notification (e.g. the patient coming to their hospital acts as a > notification). They will obtain permission to see the relevant part > of the EHR, and will start giving care, i.e. performing activities > in the Instruction, which they will document with Act_instructions > (Acts are used to document activities undertaken but not > 'prescribed', e.g. ad hoc self-administration by patient). These > Entry types by the way indicate the current state (in the state > machine sense) of the Instruction (e.g. "active", "suspended" etc). > > So we don't record 'orders' as such; we record what is to be done, > and usually by whom. Then, notifications (including humans > presenting themselves) cause things to happen, and those happenings > are documented. -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/mailman/private/openehr-clinical_lists.openehr.org/attachments/20050915/f2160683/attachment.html>
