Yet another OBSERVATION vs. EVALUATION issue

Thomas Beale thomas.beale at
Tue Aug 14 08:49:09 EDT 2012

On 14/08/2012 05:28, Koray Atalag wrote:
> Hi,
> 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?
> Cheers,
> *
> *

My favourite question.... the two criteria you can always use to decide are:

  * is it information about an 'individual' at some time, performed by
    an accepted repeatable observational / measurement / questioning
    process? Yes => Observation
  * is it primarily a comparison of observational data against any
    knowledge base (general knowledge of the physician, published
    knowledge, ontologies etc), to draw a conclusion? Yes => Evaluation

In the above case, the information ontological status should be 
preserved across tools & records: a diagnosis is still a diagnosis, 
(current) medications are still Instructions (i.e. orders) and so on.

- thomas

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