I don't deal directly with clinical EHRs, but it seems one way to handle it would be to list it as diabetes, but also have a status field. The options could be: diagnosed probable suspect patient-reported etc. Then if you want to know who has diabetes, you can run a query on the SNOMED code + status= "diagnosed".
Jim Warren <Jim.Warren at unisa.edu.au> wrote: ... 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. ... 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:[email protected]] Sent: Friday, 5 March 2004 7:54 AM To: openehr-technical at openehr.org Subject: Propositions? Hello All, ... 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.)? ... 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 --------------------------------- Do you Yahoo!? Yahoo! Search - Find what you?re looking for faster. -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/mailman/private/openehr-technical_lists.openehr.org/attachments/20040309/3ac54a63/attachment.html>
