EHR Information Model STABLE

Core model of the openEHR Electronic Health Record. Specifies the top-level EHR structure, Composition as the unit of clinical documentation, and the entry hierarchy covering observations, evaluations, instructions, and actions. EHR_STATUS carries subject identity and access control metadata, while COMPOSITION represents a clinically committed unit of information contributed by a care episode. The entry hierarchy - OBSERVATION, EVALUATION, INSTRUCTION, ACTION - maps to the main clinical documentation intents and is the primary target of archetype constraints.

Purpose

This document describes the openEHR EHR Information Model, which is a model of an interoperable EHR in the ISO RM/ODP information viewpoint. This model defines a logical EHR information architecture rather than just an architecture for communication of EHR extracts or documents between EHR systems. The openEHR definition of the EHR Extract is given in the openEHR EHR_EXTRACT Information Model.

The intended audience includes:

  • Standards bodies producing health informatics standards;

  • Academic groups using openEHR;

  • The open source healthcare community;

  • Solution vendors;

  • Medical informaticians and clinicians interested in health information.

  • Health data managers.

Related Documents

Prerequisite documents for reading this document include:

Related documents include:

Feedback

Feedback may be provided on the openEHR RM specifications forum.

Issues may be raised on the specifications Problem Report tracker.

To see changes made due to previously reported issues, see the RM component Change Request tracker.