Complications can be anything from a minor bruise to catastrophic effects and death.
Minor things like a bruise won't need to be recorded anywhere else in the record. Complications that are ongoing and are creating issues that warrant being included in the Problem List should be recorded explicitly in a Problem/Diagnosis archetype. Some may be considered an adverse reaction eg to administration of a substance and need to be recorded using the Adverse Reaction archetype There may be some that are also considered to be an adverse event and need to be recorded explicitly in an archetype for that purpose ie as a result of errors in clinical practice etc. I don't see that a complication is a candidate for an archetype in its own right, in the same way of any of these mentioned above. Cheers Heather From: openEHR-clinical [mailto:[email protected]] On Behalf Of Grahame Grieve Sent: Friday, 19 April 2013 3:33 PM To: For openEHR clinical discussions Subject: Re: Complications in an event hi The principle concern I had was definitional - did the definition of problem preclude it's use for complications of an event. There's a notion of ongoing-ness hinted at in the definition, but nothing explicit. And there's the question about whether (or which) complications of an event have ongoing implications or not. Clearly there's no definitional issue, and so I'm fine with that. Regarding the other discussion - since complications can indeed be real ongoing concerns, I think it would be good for complications to be actually problems, and explicitly, not using a reference model link. Though there might still be a use for pure complications, which might be more procedural in nature? Grahame On Fri, Apr 19, 2013 at 2:32 PM, Heather Leslie <heather.leslie at oceaninformatics.com <mailto:heather.leslie at oceaninformatics.com> > wrote: I think that many scenarios are possible. Complications can occur at the time of procedure, can become apparent at a distant time and place, or occur at same place and within the same system at a later time. In a complete EHR system there are a number of options. But it is the exchange scenario that is trickier. I think there is probably some advantage in recording something explicit about Complication within the Procedure archetype that will point to the Problem/Diagnosis for details. And similarly if the Problem/Diagnosis is entered first, subsequently pointing to a Procedure ACTION as causal will be valuable. The link both ways are useful. But if procedure does not have any notion of complication within it and is separated from the rest of the EHR in a report or message or research aggregation, there is no indication to anyone receiving the data that something untoward may have happened. Heather From: openEHR-clinical [mailto:[email protected] <mailto:openehr-clinical-bounces at lists.openehr.org> ] On Behalf Of Sam Heard Sent: Wednesday, 17 April 2013 8:59 PM To: For openEHR clinical discussions Subject: RE: Complications in an event Ian replied much inline with my views. If it is a serious complication, such as pneumonia, it will have its own diagnosis as well, which may even contain a following aetiology statement to point back. I would not directly embed the notion of a diagnosis in a procedure. Cheers Sam Dr Sam Heard FRACGP, MRCGP, DRCOG, FACHI Chairman, Ocean Informatics Chairman, openEHR Foundation Chairman, NTGPE +61417838808 <tel:%2B61417838808> _____ From: Grahame Grieve <mailto:[email protected]> Sent: 16/04/2013 9:19 PM To: For openEHR clinical discussions <mailto:openehr-clinical at lists.openehr.org> Subject: Re: Complications in an event Hi Sam Procedure does have complications, but it's a simple text / codeableText. We'd rather use Problem/Diagnosis. So the real question is, does the definition of Problem/Diagnosis exclude it's use for for complications of a specific event. Grahame On Tue, Apr 16, 2013 at 6:53 PM, Sam Heard <sam.heard at oceaninformatics.com <mailto:sam.heard at oceaninformatics.com> > wrote: Hi All It would be good to include Heather here who has been working on operation notes. I would have thought that complications within the procedure would potentially be useful. Cheers, Sam -----Original Message----- From: openEHR-clinical [mailto:[email protected] <mailto:openehr-clinical-bounces at lists.openehr.org> ] On Behalf Of Karsten Hilbert Sent: Tuesday, 16 April 2013 4:33 PM To: openehr-clinical at lists.openehr.org <mailto:openehr-clinical at lists.openehr.org> Subject: Re: Complications in an event On Tue, Apr 16, 2013 at 12:30:17PM +1000, Grahame Grieve wrote: > If you are recording an event - perhaps a procedure - and you have > complications to record, are these problem/diagnoses? That depends on clinical judgment in each case. Karsten -- GPG key ID E4071346 @ gpg-keyserver.de <http://gpg-keyserver.de> E167 67FD A291 2BEA 73BD 4537 78B9 A9F9 E407 1346 _______________________________________________ openEHR-clinical mailing list openEHR-clinical at lists.openehr.org <mailto: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 <mailto:openEHR-clinical at lists.openehr.org> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org -- ----- http://www.healthintersections.com.au / grahame at healthintersections.com.au <mailto:grahame at healthintersections.com.au> / +61 411 867 065 <tel:%2B61%20411%20867%20065> _______________________________________________ openEHR-clinical mailing list openEHR-clinical at lists.openehr.org <mailto:openEHR-clinical at lists.openehr.org> http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org -- ----- http://www.healthintersections.com.au / grahame at healthintersections.com.au <mailto:grahame at healthintersections.com.au> / +61 411 867 065 -------------- next part -------------- An HTML attachment was scrubbed... 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