As I said it?s a matter of context. Jussara R?tzsch Md, MSc Director, OpenEHR Foundation Owner, Giant Global Graph ehealth Solutions <http://www.giantglobalgraph.com.br>
On Mon, Aug 20, 2012 at 9:51 AM, Stef Verlinden <stef at vivici.nl> wrote: > > 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 > > _______________________________________________ > openEHR-clinical mailing list > openEHR-clinical at lists.openehr.org > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org > -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/pipermail/openehr-clinical_lists.openehr.org/attachments/20120820/184fbf91/attachment-0001.html>
