On 14/08/2012 05:28, Koray Atalag wrote:
>
> Hi,
>
> There's a CVD risk assessment tool I'm working on which prepopulates
> clinical info from GP software. This includes diagnoses, smoking
> status and checklist for certain medications. Note that some of the
> underlying info might be coming from previous visits (e.g. problem
> list type) but also can be newly entered as a result of GP's
> assessment. Now, regardless of what happens in GP software, when it is
> transferred onto this tool (whether automatically prepopulating and/or
> manual entry) are these Observations or Evaluations? Note that the GP
> does not make any further clinical judgement here, just rephrase
> existing data for a different purpose. My gut feeling is the former
> (Observation).
>
> I know this is tricky and has been brought to this list many times
> here but thoughts? Masters?
>
> Cheers,
>
> *
> *
My favourite question.... the two criteria you can always use to decide are:
* is it information about an 'individual' at some time, performed by
an accepted repeatable observational / measurement / questioning
process? Yes => Observation
* is it primarily a comparison of observational data against any
knowledge base (general knowledge of the physician, published
knowledge, ontologies etc), to draw a conclusion? Yes => Evaluation
In the above case, the information ontological status should be
preserved across tools & records: a diagnosis is still a diagnosis,
(current) medications are still Instructions (i.e. orders) and so on.
- thomas
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