Op 18 aug. 2012, om 10:41 heeft Gerard Freriks het volgende geschreven: > > > On 17 Aug 2012, at 19:38, Thomas Beale wrote: > >>> >>> Decisions of medical users do not depend on the fact that an item is >>> classified as "observation" or "evaluation". >> >> maybe not so much on how it is classified, but on whether it can be trusted >> or not. Erroneous conclusions can be drawn from evidence by mis-diagnosis, >> and diagnoses often have to be revisited in difficult cases. Observations >> might sometimes be declared faulty, but it is much less often the case, and >> the kinds of errors are generally less problematic than errors of diagnosis. > > > 20 something years of medical practice learned me to be humble and do not use > the word Diagnosis too lightly: > > - facts (e.g. measured things like lab results,or interventions/operations, > etc.) are trusted much better than opinions/evaluations/inferences > > - inferences are highly personal and context dependent. > (e.g. there are opinions be peers that one generally can trust more than > others. Some are never trusted. Even in the case of peers that are trusted, > each time the healthcare provider must be able to create his own opinion and > make his own judgement. > Personally I distrust all Diagnosis statements in the record. Even my own > statements. Diagnosis is always an inference about a (disease) process inside > the patient system. These processes we can no see; the only thing we can > perceive are the results of that process. It is much more realistic to record > in the EHR Reasons for Diagnostics and Reasons for Treatment than fuzzy > things such as 'Diagnosis'. The draft EN13606 Association SIAMS document > (Chapter 6) is about topics like these. > Before we can start to standardise how archetypes are produced we will have > to agree on a number of notions/concepts. > > Example: I know that within one day I suspected the patient to have shortness > of breath because of: asthma, pulmonary infection, cardiac failure and panic > attacks/hyper ventilation. These were my inferences about the process inside > the patient system. > Only one was true and had to found out via trial and error diagnostics and > trial treatments. I fear that the best we can do in most circumstances (as > GP) is to code 'Reasons for ..' and do not use the word diagnosis too often.
Isn't that what we call 'differential diagnosis'? Anyhow. I agree that these DD or reasons for should be seperated and clearly distinctable from the 'final' diangosis, preferably based on facts and deduction. Cheers, Stef -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/pipermail/openehr-clinical_lists.openehr.org/attachments/20120820/85d8ed24/attachment.html>
