Sam, The issue of recording history in a data set is what I would like to have the views of all who have had to handle the electronic management Of the History.
Currently history and clinical findings recording is not standardized and needs to be looked into. We have free text fields for data capture and this entails typing in of data by the clinician and if it is by an aide the need to sign it as having read and confirmed the data is as per the patient findings. The history is recorded in a manner that in allopathic medicine has a by and large a standard approach across countries. Has there been an attempt to model the symptoms in a generic manner?. My feeling and understanding is no. The symptoms is modelled shall be available to be called up whenever the details are to be recorded and data is captured in a granular manner. The symptoms are non volatile components in the history. The volatility is in the interpretation and conclusion thereof. Akin to the archetypes there is a strong possibility to have the symptom complexes defined and have them available for data capture. I believe that it is possible to capture the chief complaints and the details relating to the same in a manner that the information is available for data-mining and analysis at a later point of time. The objective of any record capture is to be able to provide clinical comparability and standardization across different clinicians. And all clinicians want to capture data of the patient and want to be able to use the data for analysis across a longitudinal plane of time. I would like to have your thoughts of all as to:-- can we not model the symptoms in a manner so as to make it a global element and then have the question set called up for recording the information pertaining to that element(Symptoms). An argument that may be advanced is that the symptoms can not be managed in a prepared template. I do believe that the present manner of capture of history in the Free text form is not adequate and cannot be effectively manipulated. If the symptoms are modelled they will be able to give the clinicians a protocol that may allow the capture of the symptoms in an appropriate manner to enable the clinicians to capture the information relating to each symptoms. How is the issue of capture of the details relating to Symptoms in the history data set and clinical findings needs to be addressed. Dr B S Grewal Domain Expert PGIMER - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
