Ian Cheong wrote: > Actually, the preferred method is to record the "free text utterance" of > the clinician and attach a coded term to that.
Or more than one coded term - there may be several concepts in even a short free text utterance, and they should all be encoded (preferably automagically). > Recording only a coded term loses richness and therefore usefulness for > human decision makers. > > Text can be coded after the fact with well designed tools. > > Loss of specific information is much harder to recreate. Yup, exactly. The SNOMED-CT encoded version of some clinical text should lose as little information as possible. Note that if the approach of starting with free text (or perhaps, "freeish" text - there need to be some constraints on vocab, syntax and punctuation to allow the computer to be able to encode it into SNOMED-CT concept successfully, but the constraints need not be onerous) and then adding SCT codes allows both versions to be kept in the medical record. It is not either-or. Tim C > At 5:20 pm +1000 20/7/06, Greg Twyford wrote: >> Michael Tooth wrote: >>> Peter Machell wrote: >>>> On 20/07/2006, at 12:13 PM, Greg Twyford wrote: >>>> >>>>> GPs are already coding data in programs like MD. It's diagnosis/ past >>>>> history dialogues have forced them to consciously avoid using the >>>>> available coded entries if they don't want to use them, and enter >>>>> uncoded stuff instead. >>>> >>>> Most of the MD users I see enter free text for all notes, and are >>>> offended when I suggest they first use the 'Reason' button. Isn't it >>>> time that coded diagnosis be made the default entry method, with >>>> free text a last resort? >>> >>> You might remember that MD originally only had the coded option, but >>> that the ability to put uncoded in was really the result of there not >>> being enough DOCLE codes. >>> >> >> Michael, >> >> Originally it MD it was much easier for GPs to end up with their own >> search entries like 'dia' in their notes, which were meaningless in >> terms of coding, when trying to bring up the coded diagnosis >> 'diabetes', for example. >> >> The dialogue was changed to reduce the likelihood of this by placing >> the free text box down the bottom and by changing the action of the >> search entry box at the top. It's new action ensured that one of the >> coded diagnoses was entered from the list when a search entry like >> 'dia' was used in the default search entry box at the top. >> >> This effectively forced selection of a coded diagnosis/reason/past >> history item unless the bottom 'free text' box was consciously clicked >> on. >> >> They also included the diagnosis coding tool in maintenance to allow >> uncoded or meaningless entries in the database to be corrected or >> linked with coded ones. >> >> Greg >> -- >> Greg Twyford >> Information Management & Technology Program Officer >> Canterbury Division of General Practice >> E-mail: [EMAIL PROTECTED] >> Ph.: 02 9787 9033 >> Fax: 02 9787 9200 >> >> PRIVATE & CONFIDENTIAL >> *********************************************************************** >> The information contained in this e-mail and their attached files, >> including replies and forwarded copies, are confidential and intended >> solely for the addressee(s) and may be legally privileged or prohibited >> from disclosure and unauthorised use. If you are not the intended >> recipient, any form of reproduction, dissemination, copying, disclosure, >> modification, distribution and/or publication or any action taken or >> omitted to be taken in reliance upon this message or its attachments is >> prohibited. >> >> All liability for viruses is excluded to the fullest extent permitted by >> law. >> *********************************************************************** >> >> _______________________________________________ >> Gpcg_talk mailing list >> [email protected] >> http://ozdocit.org/cgi-bin/mailman/listinfo/gpcg_talk > > _______________________________________________ Gpcg_talk mailing list [email protected] http://ozdocit.org/cgi-bin/mailman/listinfo/gpcg_talk
