Ontology based on the openEHR EHR Reference Model Revision: 4.3.2 Written in owl by Isabel Roman 1 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. 1 The root of an action specification INSTRUCCION n/a 1 INSTRUCTION G1_INSTRUCTION Act subtype Substance_adminsitration, any Act type which is really an action specification (cf and Act in the past) 1 1 1 TRANSACTION G1_TRANSACTION_VERSION 1 TRANSACCION Composition class 1 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. Composition 1 CDA DOCUMENT G1_EHR 1 RecordFolder class 1 The EHR class is the centre node of the EHR "repository" for a subject of care 1 ehr ehr 1 EHCR 1 G1_OBSERVATION_CONTENT, G1_SUBJECTIVE_CONTENT OBSERVACION Observation 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. Cluster 1 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 1 *_CONTENT 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. 1 1 Act The Item class is the clossest match for Entry as described here ClusterOCC ENTRY ENTRADA 1 1 true Composition CONTEXTO CLINICO 1 1 CLINICAL CONTEXT 1 1 1 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 TBD 1 VERSIONED TRANSACTION G1_VERSIONED_TRANSACTION TRANSACCION VERSIONADA 1 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 1 G1_SUBJECTIVE_CONTENT Entry type for evaluation statements 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 Cluster Observation FOLDER CARPETA The concept of a named folder 1 1 RecordFolder FOLDER ORGANISER Headed_section 1 ORGANIZADOR COAS::CompositeObservation 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 time of creation of the repository 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 Sub-folders of this FOLDER es persistente is persistent data datos