One thing to be clear on - we must differentiate between "not recorded" and "not there". Not recording someone's weight does not make them "weightless" (don't worry I understood the joke, but this is a serious point as well). A better example would be - not recording smoking status doesn't make the patient a non-smoker.
There are 5 possible situations I know of that can occur with data: 1. it is not recorded (nothing is recorded) 2. it was asked (e.g. by an application GUI) but remains unknown due to various reasons (patient uncounscious, refused to divulge, etc) 3. it is completely known and recorded 4. it is recorded, but there are bits missing 5. it is recorded, but in the negative (no known allergies, no previous surgery, etc etc) Cases 2, 4and 5 have not always been properly catered for in systems. Case 2 is dealt with in by the use of what i would call "data quality markers", i.e. what HL7 calls "flavours of Null". Actually, we call them that in the openEHR model, and use HL7's flavours of null (although we use them in a different way) Case 4 is dealt in openEHR by partial data types e.g. DV_PARTIAL_DATE, and with Null Flavours in HL7. Case 5 requires proper structurinng of the health record, so that negatives can be recorded; archetypes/templates help in this. - thomas beale Douglas Carnall wrote: >In my previous mail to this list (openehr-technical at openehr.org) I wrote: > >>>If I see a patient who subsequently turns out to have thyrotoxicosis, but do >>>not record the presence or absence of certain key clinical findings (e.g. >>>pulse, weight, tremor) >>> > >Hmm. If I saw a patient with an absent pulse and failed to note that >finding, either mentally or in a clinical record, I think I might rightly be >accused of being a poor observer of the human condition. Come to think of >it, a weightless patient would be interesting too :-) > >And everyone has a physiological tremor, though it is often exaggerated in >moderate to severe untreated thyrotoxicosis. > >So in fact, now I come to think about it again, I didn't mean presence or >absence of pulse, weight or tremor, but presence or absence of--all right, >use the word, fuzzy, values for pulse, weight or tremor. > >But you knew what I meant didn't you? > >;-) > >D. > -- .............................................................. Deep Thought Informatics Pty Ltd mailto:thomas at deepthought.com.au open EHR - http://www.openEHR.org Archetype Methodology - http://www.deepthought.com.au/it/archetypes.html Community Informatics - http://www.deepthought.com.au/ci/rii/Output/mainTOC.html .............................................................. - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
