A few of my thoughts abd advice: 1- have a look at the CEN/ISO standard defining the concepts related to Continuity of Care. 2- For may years Dutch GP’s use the SOEP method of documenting the provision of health and care. (SOEP=Subjective, Objective, Evaluation, Plan) 3- For many years we collected data items under the heading of Problem in a Problem List f(PrL) or use by one Healthcare Provider (HcP) 4- Then the Episode (Ep) was introduced because GP’s started to collaborate with other HcP’s. 5-The progression of the developments in the Patient System over time cause changes in the title of the PrL and Ep. E.g. PL title = Reason for Encounter (cough); then PL title=Pulmonary infection; then PL title=Tuberculosis; Ep titles probably will have the same titles. 6- The Continuity of Care standard provides a lot a fine detail. In order to make things simple I used my compatible version of the medical treatment model of that standard, Observation in the Patient system (PS) that is documented Evaluation of the Observations, PrL, EL, etc leading to differential diagnosis, working diagnosis or determined diagnosis Planning. Differential Diagnosis will lead to plans with goals to prove or disprove diagnosis or start treatment Actions. Plans a re broken down to actioned and documented procedures influencing the PS or other (non-PS) systems for administrative purposes such as data exchange, requests, scheduling, updating the PL and/or Ep Followed by Observations that are documented.
Steps i to 4 each have a fixed Pattern Archetype as ENTRY archetype All PS and Ep’s are collected in distinct FOLDERs the FOLDER shows the progress of the health and care process over time. Gerard Freriks +31 620 34 70 88 +31 182 22 59 46 [email protected] Kattensingel 20 2801 CA Gouda the Netherlands > On 26 Jun 2019, at 22:30, Thomas Beale <[email protected]> wrote: > > > > On 26/06/2019 11:07, Thomas Beale wrote: >> As yet, the machinery to do this mostly exists, but there is little in the >> way of standardised patterns or usage of it to achieve any kind of >> standardised 'problem' document (NB: not the same as 'problem list' - which >> is one level up, and is a managed list of issues considered to be problems, >> usually inclding current Dxs such as diabete >> > other than the SOAP heading structure, of course, as described in another > post on this thread. > > Thomas Beale > Principal, Ars Semantica <http://www.arssemantica.com/> > Consultant, ABD Project, Intermountain Healthcare > <https://intermountainhealthcare.org/> > Management Board, Specifications Program Lead, openEHR Foundation > <http://www.openehr.org/> > Health IT blog <http://wolandscat.net/> | Culture blog > <http://wolandsothercat.net/> | The Objective Stance > <https://theobjectivestance.net/>_______________________________________________ > openEHR-clinical mailing list > [email protected] > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
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