Yet another OBSERVATION vs. EVALUATION issue
k.atalag at nihi.auckland.ac.nz
Tue Aug 14 00:28:21 EDT 2012
There's a CVD risk assessment tool I'm working on which prepopulates clinical info from GP software. This includes diagnoses, smoking status and checklist for certain medications. Note that some of the underlying info might be coming from previous visits (e.g. problem list type) but also can be newly entered as a result of GP's assessment. Now, regardless of what happens in GP software, when it is transferred onto this tool (whether automatically prepopulating and/or manual entry) are these Observations or Evaluations? Note that the GP does not make any further clinical judgement here, just rephrase existing data for a different purpose. My gut feeling is the former (Observation).
I know this is tricky and has been brought to this list many times here but thoughts? Masters?
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