Diagnosis is a fuzzy term. It is used and mis-used and creates a lot of confusions. A 'diagnosis' many time does not describe a disease process inside the patient system, but is a way to collect or spend money or to explain a next round of diagnostics or treatments.
All terms like these need to be formally defined: http://www.datadictionary.nhs.uk/contsys/ Gerard Freriks +31 620347088 gfrer at luna.nl On 18 Aug 2012, at 14:29, Jussara wrote: > Yet we use this term a lot, as a hypothese or as a differential diagnosis, or > even as a past diagnose, not forget to billing purposes and DRG calculus. > Don't know how you could avoid it here in Brazil, where ICD 10 is used to > code everything, actually it is the only classification used in large scale > in Brazil, where even CIAP isn't used by the primary care doctors. All > analytics of health status and conditions as well decisions support tools in > Brazil use ICD as the clinical vocabulary, and you know what happens if you > retrieve those codes without having the context. I used to work with record > linkage and know how inaccurate can it be to do a query using ICD and was for > that reason that we began to seek for modeling information, because it's > essential to give context wherever the ICD is used. The ontologic based > openEHR RM was found by experts here the model that is closer to our need. I > think not only us, as international experts gathered at CIMI just came to > the same opinion. > Talking on the difference of evaluation and observation, I thought we're > talking on modeling not on the value of using any concept or entry. If most > clinicians don't trust diagnosis or inferences, they do it everyday, because > it's our jobs to make inferences! There are them which lead to the > instructions we give. > > Regards > > Jussara Rotzsch -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/pipermail/openehr-clinical_lists.openehr.org/attachments/20120819/c86b28ed/attachment.html>
