Yet another OBSERVATION vs. EVALUATION issue

Gerard Freriks gfrer at luna.nl
Sun Aug 19 01:15:27 EDT 2012


Diagnosis is a fuzzy term.

It is used and mis-used and creates a lot of confusions.
A 'diagnosis' many time does not describe a disease process inside the patient system, but is a way to collect or spend money or to explain a next round of diagnostics or treatments.

All terms like these need to be formally defined:
http://www.datadictionary.nhs.uk/contsys/

Gerard Freriks
+31 620347088
gfrer at luna.nl




On 18 Aug 2012, at 14:29, Jussara wrote:

> Yet we use this term a lot, as a hypothese or as a differential diagnosis, or even as a past diagnose, not forget to billing purposes and DRG calculus. Don't know how you could avoid it here in Brazil, where ICD 10 is used to code everything, actually it is the only classification used  in large scale  in Brazil, where even CIAP isn't used by the primary care doctors. All analytics of health status and conditions as well decisions support tools in Brazil use ICD as the clinical vocabulary, and you know what happens if you retrieve those codes without having the context. I used to work with record linkage and know how inaccurate can it be to do a query using ICD and was for that reason that we began to seek for   modeling   information, because it's essential to give context wherever the ICD is used. The ontologic based openEHR RM was found by experts here the model that is closer to our need. I think not only us,  as international experts gathered at CIMI just came to the same opinion.
> Talking on the difference of evaluation and observation, I thought we're talking on modeling not on the value of using any concept or entry. If most clinicians don't trust diagnosis or inferences, they do it everyday, because it's our jobs to make inferences!  There are them which lead  to the instructions we give.
> 
> Regards
> 
> Jussara Rotzsch

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://lists.openehr.org/pipermail/openehr-clinical_lists.openehr.org/attachments/20120819/c86b28ed/attachment.html>


More information about the openEHR-clinical mailing list