Jim Patients often report that they have diabetes and clinicians usually believe them. Infact it would be negligent not to without good reason. So we are used to doing that. Entering the problem in their problem list is something that increases the scope of the information.
We have added diagnostic criteria to diagnosis - so we might be able to keep track of these in future. In the non communicating health world we and Jim are used to the scenario is more problematic. The future (and openEHR) will hopefully remove the need to enter data in multiple ways. Specifically - openEHR can attribute the composition, the entry and the addition to the problem list. We believe this is sufficient. A patient reporting diabetes would not be entered as a diagnosis unless the clinician judged this to be the case. Recording that a patient said it is possible as free text, or as the answer to a question as I have stated earlier. Cheers, Sam Jim Warren wrote: > I'd be very interested in a detailed explanation apropos to Matias' query. > Among other things, this question seems important for home monitoring contexts > as well as questionnaires filled out in the doctor's office. > > Normally a contact note is attributed to a provider, so that takes care of the > idea that Dr X records Diabetes or Nurse J records diabetes. However, if > Nurse > J is not *diagnosing* diabetes, but recording that the patient *says* they > have > diabetes - well, that's different. Presumably the entry could be organised > under the Subjective component of the contact note (?). Nonetheless, it would > seem dangerous to assign the SNOMED or ICD *diagnosis* code for Diabetes (and > of what type?), since a subsequent query could pull this out of context as a > provider diagnosis. How is the best way to represent that 'the patients says > they were diagnosed with diabetes'? > > All of the above might seem less academic if the disease in question were one > where the patient was more likely to be in error, or particularly to give a > false positive. > > I assume that the prompt would NOT be modelled in the archetype, but perhaps > implied by the actual code used and otherwise left up to the application to > provide. (Again, I'm not sure - please enlighten me!) > > Jim Warren > > Assoc. Prof. Jim Warren > Advanced Computing Research Centre > University of South Australia > Mawson Lakes SA 5095 AUSTRALIA > > -----Original Message----- > From: Matias Klein [mailto:matias at ethidium.com] > Sent: Friday, 5 March 2004 7:54 AM > To: openehr-technical at openehr.org > Subject: Propositions? > > Hello All, > > We are making incredible progress with the openEHR framework! Recently > we faced a requirement to create patient-facing data capture tools. > Unfortunately we can't seem to find a place in the openEHR model where > these types of propositions fit cleanly. > > For example if I have a patient intake form that has the question, "Do > you have diabetes?" Obviously the patient's answer to the question > could be modeled as an observation of "diabetes" mapped by the > DV_CODED_TEXT datatype to SNOMED or ICD. However what I don't > understand is how the proposition "Do you have diabetes?" should be > modeled? > > Should a "diabetes" archetype have a proposition field where a question > can be stored as a string? How would multiple perspectives be modeled > (i.e. question to patient, question to doctor, question to family > member, etc.)? > > Your assistance in helping me understanding this issue is greatly > appreciated. > > Kind Regards, > > Matias > > ============ > Matias Klein > Ethidium Health Systems > 3993 Huntingdon Pike - Suite 108 > Huntingdon Valley, PA 19006-2623 > USA > Office: (215)938-8630 > Fax: (215)938-7301 > http://www.ethidium.com > - > If you have any questions about using this list, > please send a message to d.lloyd at openehr.org > - > If you have any questions about using this list, > please send a message to d.lloyd at openehr.org > - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
