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| Data Entry Context | Constraints on Values | Interpretation of Recorded Data | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Initial diagnosis on an encounter or admission form | A concept recorded in this data entry context should be a subtype of
| The fact that this is an "Initial diagnosis" data entry context needs to be captured so that the record can be appropriately interpreted.
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| Surgical history as part of past medical history | A concept recorded in this data entry context could either be:
| The "Past History" data entry context needs to be captured so that the record can be appropriately interpreted. It must be possible to distinguish a past history record of a procedure from a contemporaneous record of the same procedure.
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| Symptom check list with yes or no options for each symptom | Each question should be bound to a concept that represents the relevant symptom. These concepts should be subtypes of
The simplest way to represent the "yes" and "no" answers to a question like this is to record the relevant finding concept if the answer is "yes" and not to create a record if the answer is "no". However, where the answer "no" has clinical significance, alternative approaches discussed in the next column may be preferable.
| The simple approach suggested in the previous column does not explicitly record negative answers. However, in many cases, a negative response has its own significance and does need to be recorded.
Similarly, there may be questions that have 3 alternative answers (e.g. "yes", "no", "don't know"). In these cases an approach is needed to distinguish between the available responses.
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