Ontology based on the openEHR EHR Reference Model Revision: 4.3.2 Written in owl by Isabel Roman
Not to be used for plan items which are only specified in general terms, e.g. "comence bronchodilator"
Used for any actionable statement such as medication and therapeutic orders, monitoring, recall and review. Enoug details must be provided for the specification to be excuted by an actor.
INSTRUCCION
INSTRUCTION
Act subtype Substance_adminsitration, any Act type which is really an action specification (cf and Act in the past)
TRANSACTION
TRANSACCION
One version in a VERSIONED_TRANSACTION. A transaction is considered the unit of modification of the record, the unit of transmission in record extracts, and the unit of attestation by authorising clinicians. In this latter sense, it may be considered equivalent to a signed document.
The EHR class is the centre node of the EHR "repository" for a subject of care
ehr
G1_OBSERVATION_CONTENT, G1_SUBJECTIVE_CONTENT
OBSERVACION
OBSERVATION is used for all notional objective (i.e. measured in some way) observations of phenomenena as well as all statements or opinios (i.e. subjective data) about things in the past.
not used for future statements of any kind, including instructions, intentions, plans etc...
Entry subtype for all clinical data in the past or present, i.e. which (by the time it is recorded) has already ocurred. OBSERVATION data is expressed using the class HISTORY_T, which guarantees that it is situated in time.
OBSERVATION
COAS::HealthRecordEntry and COAS::ObservationQualifier
COAS::HealthRecordEntry and COAS::ObservationQualifier, a generic class which is used to represent context attributes which are concretely modelled here
The abstract parent of all ENTRY subtypes. An ENTRY is the root of a logical item of "hard" clinical information created in the "clinical statement" context. It is also the minimal unit of information any query should return.
The Item class is the clossest match for Entry as described here
ENTRY
ENTRADA
CONTEXTO CLINICO
CLINICAL CONTEXT
Documents the clinical context of the clinical session (or encounter). The context information recorded here are independent of the attributes recorded in the version audit, which document the "system interaction" context, i.e. the context of a user interacting with the health record system. Clinical sessions include patient contacts, and any other business activity, such aas pathology investigations which take place on behalf of the patient
VERSIONED TRANSACTION
TRANSACCION VERSIONADA
Version-controlled transaction abstraction, defined by inheriting VERSION_REPOSITORY_TRANSACTION
Should not be used for actionable statements such as medication orders these are represented with the INSTRUCTION type
EVALUACION
Used for all kinds of statements which evaluate other information, such as interpretations of observations, diagnoses, differential diagnoses, hypotheses, problem assessments and plans
EVALUATION
CARPETA
FOLDER
ORGANISER
ORGANIZADOR
Represents a heading in a heading structure, or "organiser tree"
Created according to archetyped structures for typical headings such as SOAP, physical examination, but also pathology result heading structures
Should not be used instead of ENTRY hierarchical structures.
contenido
content
The clinical session content of this transaction, i.e. the information generated in the clinical session
participantes
participations
Parties involved in the clinical session. These would normally include the physician and often the patient (but not the latter if the clincal session is a pathology test for example)
feeder audit
auditor origen
Audit trail from non-openEHR system of original commit of information ofrming the content of the current item.
The HCF in the health system which took part in the encounter; usually, this is where the encounter physically took place, but not in the case of patinet home visits, internet contacts or emergency care.
servicio del sistema sanitario
health care facility
subject
sujeto
otras participaciones
Other participations at ENTRY level-archetypable
other participations
contexto
The clinical session context of this transaction, i.e. the contextual attributes of the clinical session
context
identificador de la guia (protocolo)
guideline id
Identifier guideline creating this action if relevant
session time
intervalo de la sesion
Start and endd times of the clinical sesion
The actual location where the session occurred, e.g. "microbiol lab 2", "home", "ward A3" and so on
localizacion
location
directorio
Optional directory structure for this EHR
directory
elementos contenidos
content items
Ordered list of content items under this organiser, which may include: more ORGANISERs ENTRYs
The list of references to versioned transactions in this folder. Since more than one folder can include the same transaction, this relationship is an association.
transactions
transacciones
accion
description of the action to be executed
action
configuration data mappings from archetyped model of action
profile
perfil
otros contextos
Other optional context which will be archetyped.
other context
contributions
contribuciones
List of contributions causing changes to this EHR. Each contribution contains a list of versions, which may include paths pointing to any number of VERSIONABLE items items of type TRANSACTION and FOLDER_TREE
instante de creacion
time created
current state of the action in a state machine description
estado
state
practice setting
The practice setting, e.g. "outpatient facility", "hospital unit", "general practice" etc, which may be optionally coded. HL7 PracticeSetting domain may be useful for this.
catacteristicas practicas
Master list of all transaction references in this EHR
todas las transacciones
all transactions
Description of how and/or why th information in this entry was arrived at. For OBSERVATIONS, this is a description of the method or instrument used. For EVALUATIONS, how the evaluation was arrived at. For INSTRUCTIONS, how to execute the instruction. This may take the form of references to guidelines, including manually folowed and executable; knoledge references such as paper in Medline; clinical reasons within a largercare process
protocolo
protocol
provider
Id of provider of statement in this ENTRY, which might be: the patient a patient agent (parent, guardian...) the clinician a device or software
proveedor
Optional act identifier used by e.g. a workflow system for an act to which this ENTRY correspondes in some way. This identifier might have internal syntax and meaning to an external processor.
id del acto
act id
es persistente
is persistent
data
datos