Karsten Hilbert wrote: >>and I'm suggesting that information should be >>reduced as much as possible to a standard set of codes. >> >> >If that means to reduce what I can put in my clinical notes >then No, thanks. I use the fuzziness of German when writing >progress notes to myself in order to capture the degree of >fuzziness of the specific ailment at hand and augment that with >commonly used scales (GCS, APGAR, Janda, ...) to map my notes >to more standard values when writing referral letters etc being >sent to colleagues. Of course I am not perfect in this and >could make use of a tool that facilitates my correctly >applying standard scales. > I agree with Karsten - there is a basic principle here (and in openEHR). The physician must be able to write what they want. Now...if they want to write a sentence with the words "possible Dengue Fever infection" then the software may be able to code "Dengue Fever" using Snomed or some other ontology; the result would be narrative with key coded terms. Peter Elkin's group at Mayo have shown how they do the reverse (what Gerard Freriks mentioned also) - a post hoc coding & structuring of the text.
Philippe Ameline's Odyssee product on the other hand uses a structured input system for recording endoscopy investigations, and the specialists are happy with it. But - he has a nice, detailed lexicon of terms to draw on, and it seems it has everything they want; when it doesn't, they just write a free text field. Even so, the principle i mention above seems to be preserved. So - how structured the input I suspect depends more on the type of medicine or specialty than some overarching rule. - thomas beale - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
