Re: Comment on openEHR-EHR-CLUSTER.inspection-skin-wound.v1 archetype
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Hi Otavio, Some suggestions... My approach would be to build a template (- I'm obviously using the Ocean tools) comprising a COMPOSITION to capture an encounter - I assume this is recording a consultation in primary care or emergency for a patient after an animal bite. You can use SECTION/s if you need them. History: The Story entry is a great start for capturing the history - enables ability to simply record a free text narrative. If you want more detail, I'd consider using the CLUSTER.health_event or its specialisation CLUSTER.health_event-trauma. See if you think either of these will be fit for purpose, or if they need some refining. In principle it would be better to enhance these existing archetypes to record the bite situation but if you find there are a number of specific attributes we could think of specialising for this. I suspect that this will not be neccessary if we think through how to improve the existing ones first. Remember these are all draft at present and this is the kind of use case that will help to improve them prior to publishing. So I would hope that the history and details should be largely captured just using these existing archetypes - let me know how it goes. Examination findings: I'd use the OBSERVATION.exam archetype as the base ENTRY class. In a template it can be renamed to 'Examination of Bite'. There is ability to record a free text narrative again, OR insert detailed examination CLUSTERs into the slot: CLUSTER.inspection-skin-wound, and maybe the generic palpation archetypes. What requirement do you have for examination of the wound? Conclusion: EVALUATION.problem-diagnosis Plan & Follow-up: There are a few possible INSTRUCTIONs already in CKM that might be useful - depends what else you need. Hope this helps. Happy to keep chatting. Suggestions from others are welcome.... ;-) Regards Heather On 6/02/2010 1:11 PM, Otavio Silva wrote: Hi Heather, What you wrote make a lot of sense... I coudn't get trought the Waves yet, I already told Ian... I must be doing something very silly... I am in team of Luciana from UFF (Brazil, RJ) and we are working on the OSHIP application for openEHR, by now I am aiming to make a decision support engine using pyCLIPS on rabies prophilaxis, where the most important thing is whether the wound is done by an animal and the second is where it was. So, if I could understand properly, and to be in consonance, I should work in an archetype that specialises the history-taking process (a specialisation of openEHR-EHR-OBSERVATION.story.v1?), to work on an archetype of bodyparts and suggest that the wounds archetype has a link to some bodyparts archetype... I guess is quite a lot of work to do... ;-) Otavio --
Dr Heather Leslie
MBBS FRACGP FACHI Director of Clinical Modelling Ocean Informatics Phone (Aust) +61 (0)418 966 670 Skype - heatherleslie Twitter - @omowizard |
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