Clinical Scenario: Encounter Synopsis
At this point in the consultation, we’ve captured a lot of information about an encounter. We have structured data across multiple archetypes: history, vitals, clinician judgement and instructions.
However, in clinical practice, doctors often want one more thing: a concise summary that brings everything together.
Summarizing the encounter
Even when we capture data in a highly structured way, it is still common for clinicians to write a narrative overview. This serves two purposes:
- it allows another practitioner to quickly understand what happened
- it preserves the clinician’s interpretation and emphasis, which may not be fully expressed through structured fields alone
Adding a clinical synopsis
On searching the CKM, you can find a suitable EVALUATION archetype: clinical_synopsis.v1
The purpose of this archetype is to record a narrative summary of the patient from the perspective of a healthcare provider, including interpretation and clinical context. This aligns perfectly with what we want to capture.
- a free-text synopsis This allows the clinician to summarize the encounter in their own words.
In practice, clinicians often read the narrative first, and the structured data supports decision making and analytics. Both are needed for a complete clinical record.
Recap
With this, the initial assessment workflow is complete.
Across these lessons, we’ve seen how to:
- choose the right archetypes based on clinical intent
- distinguish between the different classes of archetypes
- combine structured and unstructured data
- and build a realistic, end-to-end encounter template
At this point, you should be comfortable taking a real-world clinical form and translating it into an openEHR template step by step.
In the next lesson, you’ll do an exercise related to this scenario.
