ACTION archetypes

ACTION archetypes An example of how an Instruction for a Procedure will be recorded in an Electronic Health Record using an ACTION archetype.

Instruction/Action for Procedure ACTION = information recorded as a result of performing the Instruction, including the planning phase

INSTRUCTION attributes
In addition, from the open EHR Reference Model (RM):
Author/Composer
Patient
Date of the Instruction
Expiry time
Note: These elements from the RM are universally availably and not modelled explicitly in the archetype
Explicitly modelled

ACTION attributes Explicitly modelled
From the RM:
Author/Composer
Patient
Participations
Time of being performed
ISM transition

ACTION Pathway attributes Planned Postponed Cancelled Active Suspended Cancelled Completed Scheduled Clinicians name the steps in terms that make sense for the clinical purpose  mapping steps in any care pathway process to states in the ISM. These are the steps in the carrying out of an Instruction where it makes clinical sense to record some data in the EHR States are also defined in the Reference Model (RM) (aka the ‘Instruction State Machine’ (ISM)). NAMED CLINICAL STEPS RM STATES

Record ‘Procedure planned’ instance Procedure Planned Procedure Scheduled Procedure Performed Failed Attempt Procedure Abandoned Procedure Completed Reason for procedure Description of planned procedure Device planned RM States Creation of an Instruction often coincides with the creation of a corresponding ACTION recording appropriate data against the Planned pathway step. Simultaneous INSTRUCTION & ACTION

Record ‘Procedure Scheduled’ instance Procedure Planned Procedure Scheduled Procedure Performed Failed Attempt Procedure Abandoned Procedure Completed Planned duration Scheduled Date/Time

Record ‘Procedure Performed’ instance Procedure Planned Procedure Scheduled Procedure Performed Failed Attempt Procedure Abandoned Procedure Completed Description of procedure performed Duration of procedure Start time of procedure Device used

Record ‘Failed Attempt’ instance Procedure Planned Procedure Scheduled Procedure Performed Failed Attempt Procedure Abandoned Procedure Completed Description of procedure performed Reason why it failed Duration of failed attempt Start Date/Time for procedure Device used

Record ‘Procedure Abandoned’ instance Procedure Planned Procedure Scheduled Procedure Performed Failed Attempt Procedure Abandoned Procedure Completed Reason for abandonment

Record ‘Procedure Completed’ instance Procedure Planned Procedure Scheduled Procedure Performed Failed Attempt Procedure Abandoned Procedure Completed Description of Procedure completed Record the completion of the Procedure…& close the loop initiated by the Instruction

Direct from the openEHR RM…
The Instruction and Action classes are designed to satisfy the following requirements:
All kinds of interventions, from simple medication orders to complex multi-drug courses should be representable using the same model;
Instructions should always have a narrative expression, with an optional machine-processible expression in cases where automation will be used;
The freedom must exist to model any particular intervention in as much or little detail as required by circumstances;
Clinicians must be able to specify Instruction steps in their own terms, i.e. using terms like
“ prescribe”, “dispense”, “start administering”, etc;
Instructions representing diverse clinical workflows must be queryable in a standard way, so that it can be ascertained what Instructions are ‘active’, ‘completed’ and so on for a patient;
It should be possible to provide a coherent view of the state of execution of an Instruction
even if parts of it have been executed in different healthcare provider environments;
It must be possible to record ad hoc actions in the record, i.e. acts for which no Instruction
was defined (at least in the EHR in question);
Instructions must integrate with notification / alert services;
An interoperable expression of computable workflow definitions of Instructions will be supported.
Reference: open EHR EHR Information Model - http://www.openehr.org/releases/1.0.2/architecture/rm/ehr_im.pdf
© Ocean Informatics 2011

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ACTION archetypes

by Ocean Informatics on Jul 11, 2011

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