ID

23536

Description

Derived from www.openehr.org . Use to record a narrative, summary view of the patient's health. This unstructured summary may include identified health issues; health care provided; associated interpretation; patient understanding; and enable communication about some of the softer, more subjective aspects of the patient’s experience and journey. Most commonly this summary is likely to be related to a specific health event such as a specific consultation or hospital admission, but may also be used to summarise the patient's health experience over varying time periods. In practice, Clinical Synopsis is a meta observation that will complement the existing structured clinical record, allowing for expression of subtle, subjective or interpretive information about the patient that might not otherwise be obvious through structured data alone, providing balance and context to the EHR record. For example, a Clinical Synopsis can communicate a succinct summary of the patient's hospital admission as one component of a comprehensive and structured Discharge Summary document.

Lien

www.openehr.org

Mots-clés

Versions (2)

1. 08/07/2017 08/07/2017 - Martin Dugas
2. 08/07/2017 08/07/2017 - Martin Dugas

Téléchargé le

8 juillet 2017

DOI

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Licence