[Gnumed-devel] address@hidden: Re: Inspection vs Observation]

[Karsten Hilbert]

This is the sort of insight (and eventually tools for
handling it) that can be gained from OpenEHR:

----- Forwarded message from Gerard Freriks <address@hidden> -----

> My contribution.
>
> Definition of Patient State and the 4 Clinical Entry Archetypes
>
> Entry DCM/Archetype
>
> Definition
>
> Patient System
> The ensemble (states and processes) of the constituting parts of the  
> body, the body as a whole and its social and other environment of a  
> person that is the recipient of healthcare delivery.
> Observation
> An archetype that defines what needs to be documented about a specific  
> state in the patient system at a point in time using the faculties of  
> seeing, hearing, tasting, touching, smelling, or via a medical device.
> Evaluation
> An archetype that defines what needs to be documented about a process in 
> the patient system using observations, expertise and knowledge.
> Instruction
> An archetype that defines what needs to be documented about intended  
> actions to change the state or process in the patient system.
> Action
> An archetype that defines what needs to be documented about events that 
> change (or could change) states or processes in the Patient System
>
>
> Gerard Freriks
>
>
>
> On Behalf Of Pariya Kashfi
> On 4, May, 2009, at 7:58 , Sam Heard wrote:
>
>> Considering these questions:
>> 1- (asking patient) : Have you noticed any swelling of your salivary  
>> glands?
>> 2-  Inspection of salivary glands (Actually for this one, based on a  
>> suggestion from Ian I intend to create Cluster: Inspection- Salivary  
>> glands)
>>
>> Should one just create one Observation or Cluster to use it for both  
>> cases or do you suggest another way of modeling these two concepts?
>> As you may notice, the first question is info. that the clinician  
>> receive from the patient by just listening and in the second one we  
>> will have a real physical inspection.
>> I have the same situation for Asking about disease history and  
>> observation and evaluation. e.g:
>> 1- Do you have HIV?
>> 2- one observation that may lead to a evaluation of HIV
>>
>> In my view, any history of diseases has been actually an Evaluation at 
>> its time! but what if for now, just this info  like the name of the 
>> disease is important for me to keep track of?
>>
>

> _______________________________________________
> openEHR-clinical mailing list
> address@hidden
> http://lists.chime.ucl.ac.uk/mailman/listinfo/openehr-clinical

----- End forwarded message -----

-- 
GPG key ID E4071346 @ wwwkeys.pgp.net
E167 67FD A291 2BEA 73BD  4537 78B9 A9F9 E407 1346