Yet another OBSERVATION vs. EVALUATION issue

Karsten Hilbert Karsten.Hilbert at gmx.net
Sat Aug 18 06:51:31 EDT 2012


> 20 something years of medical practice learned me to be humble and do not
> use the word Diagnosis too lightly:

...

> Example: I know that within one day I suspected the patient to have
> shortness of breath because of: asthma, pulmonary infection, cardiac failure and
> panic attacks/hyper ventilation. These were my inferences about the process
> inside the patient system.
> Only one was true and had to found out via trial and error diagnostics and
> trial treatments. I fear that the best we can do in most circumstances (as
> GP) is to code 'Reasons for ..' and do not use the word diagnosis too
> often.

That's why in GNUmed there isn't even a field labelled "Diagnosis".
We offer that field under "Assessment" (as from SOAP) and "Episode" (under
which SOAP notes are stored). Regarding Episodes (and Health issues)
clinical certainties thereof can be recorded:

- sign
- cluster of signs
- syndromic diagnosis
- scientifically proven diagnosis

Karsten




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