Yet another OBSERVATION vs. EVALUATION issue

Gerard Freriks gfrer at luna.nl
Sun Aug 19 01:10:32 EDT 2012


It must be clear that one is able to define these terms.
But others do the same and do it differently.

Examples:
Symptom:
1- an observable as percieved and communicated by a patient 
2- an observable fact about the patient (system)
3- an observable fact about the patient system deemed relevant by a healthcare provider
4- the prototypical phenomenon that can be observed and belongs to a set of possible phenomena caused by a particular disease

These are paraphrased definitions hat I remember.

So what to do?
All 4 are defined but not the same.

This is why CEN/ISO Concepts for Continuity of Care defines many of the terms we need in healthcare.
http://www.datadictionary.nhs.uk/contsys/
They use a co-ordinated, modeled, set of terms we can use as reference point when we all use our own definitions locally.

Gerard Freriks
+31 620347088
gfrer at luna.nl




On 18 Aug 2012, at 14:13, Karsten Hilbert wrote:

>> lets ditch the term 'Diagnosis' completely.
>> Or use it only when we are -as you write- scientifically certain.
>> And use other terms. We (EN13606 Association) prefer the 'Reasons for ...'
>> type of terms, because that is what they do in real life.
>> They are the excuses to do something (or nothing); they are the cost
>> drivers in healthcare; they must be documented.
>> 
>> Words like 'symptom', 'sign', 'syndrome', 'diagnosis', are fuzzy terms
>> that can mean too many things.
> 
> They do have intuitive clinical meanings though:
> 
> symptom/sign:
> 
> a *single* "thing" related to a patient's health deemed
> clinically relevant by the provider
> 
> cluster of symptoms/signs:
> 
> a group of probably related symptoms/signs happening at the
> same time, suggestive to the provider to be of common origin
> 
> syndromic diagnosis:
> 
> cluster(s) of signs/symptoms which incur sufficient confidence
> in the provider to "call this" a certain affliction - IOW a
> clinical diagnosis, differential diagnosis, considered diagnosis
> 
> Those definitions work quite well in GP land.
> 
> Karsten
> 
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