Hi Grahame Just to offer a slight variation on this theme, I think the exact implementation may depend on whether you are working inside an EHR or at the boundaries eg for messaging or reporting. In a full EHR environment the complication will arise separately to the procedure and will be recorded as a separate event using a problem diagnosis record. However when constructing eg a discharge summary or audit report the clinician may not have a full EHR and so no record to link to. For reporting / simplicity purposes they may in any case want or need to resolve a linked complication problem code into the procedure record itself.
This is a sufficiently common and formalism agnostic issue that it might be worth trying to develop some common guidance. Ian Dr Ian McNicoll Clinical modelling consultant Ocean Informatics Mobile +44 (0) 775 209 7859 Skype imcnicoll On 16 Apr 2013, at 23:32, Grahame Grieve <grahameg at gmail.com> wrote: ok thanks Grahame On 17/04/2013, at 8:06 AM, "Heather Leslie" < heather.leslie at oceaninformatics.com> wrote: Hi Grahame, The Complications data element is a DV_Text. So it can capture narrative text. It also has a 0..* Links available as a RM attribute, and so it could be used to Link to a formal recording of a Problem or Diagnosis using the specific Problem/Diagnosis archetype, such that it could be added to a Problem List etc if the clinician thought it warranted it. >From CKM, Link attributes: ?A Link may be made between any two nodes in an EHR. Multiple links can be made and the meaning and type of link defined for each. For example, Links can be used to to associate elements of a Care Plan; to link a supporting Observation to a Diagnosis; or to link a Procedure and the Diagnosis recording a complication. PDF <http://www.openehr.org/releases/1.0.2/architecture/rm/common_im.pdf> UML<http://www.openehr.org/local/releases/1.0.1/uml/Browsable/_9_0_76d0249_1109008323448_872834_917Report.html> Heather *From:* openEHR-clinical [mailto:openehr-clinical-bounces at lists.openehr.org<openehr-clinical-bounces at lists.openehr.org>] *On Behalf Of *Grahame Grieve *Sent:* Tuesday, 16 April 2013 12:30 PM *To:* For openEHR clinical discussions *Subject:* Complications in an event If you are recording an event - perhaps a procedure - and you have complications to record, are these problem/diagnoses? the existing archetypes simply have complications : text (maybe coded). But aren't these problems, just problems that may only have existed in the context of an event? So you could actually use problem/diagnosis? Grahame -- ----- http://www.healthintersections.com.au / grahame at healthintersections.com.au/ +61 411 867 065 _______________________________________________ openEHR-clinical mailing list openEHR-clinical at lists.openehr.org http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org _______________________________________________ openEHR-clinical mailing list openEHR-clinical at lists.openehr.org http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/pipermail/openehr-clinical_lists.openehr.org/attachments/20130417/2127ec0f/attachment-0001.html>
