Yet another OBSERVATION vs. EVALUATION issue

Jussara macedo jussara.macedo at
Mon Aug 20 09:07:00 EDT 2012

As I said it´s a matter of context.
Jussara Rötzsch
Md, MSc
Director, OpenEHR Foundation
Owner, Giant Global Graph ehealth Solutions

On Mon, Aug 20, 2012 at 9:51 AM, Stef Verlinden <stef at> wrote:

> Op 18 aug. 2012, om 10:41 heeft Gerard Freriks het volgende geschreven:
> On 17 Aug 2012, at 19:38, Thomas Beale wrote:
> Decisions of medical users do not depend on the fact that an item is
> classified as "observation" or "evaluation".
> maybe not so much on how it is classified, but on whether it can be
> trusted or not. Erroneous conclusions can be drawn from evidence by
> mis-diagnosis, and diagnoses often have to be revisited in difficult cases.
> Observations might sometimes be declared faulty, but it is much less often
> the case, and the kinds of errors are generally less problematic than
> errors of diagnosis.
> 20 something years of medical practice learned me to be humble and do not
> use the word Diagnosis too lightly:
> - facts (e.g. measured things like lab results,or
> interventions/operations, etc.) are trusted much better than
> opinions/evaluations/inferences
> - inferences are highly personal and context dependent.
> (e.g. there are opinions be peers that one generally can trust more than
> others. Some are never trusted. Even in the case of  peers that are
> trusted, each time the healthcare provider must be able to create his own
> opinion and make his own judgement.
> Personally I distrust all Diagnosis statements in the record. Even my own
> statements. Diagnosis is always an inference about a (disease) process
> inside the patient system. These processes we can no see; the only thing we
> can perceive are the results of that process. It is much more realistic to
> record in the EHR *Reasons for* Diagnostics and Reasons for Treatment
> than fuzzy things such as 'Diagnosis'. The *draft* EN13606 Association *
> SIAMS* document (Chapter 6) is about topics like these.
> Before we can start to standardise how archetypes are produced we will
> have to agree on a number of notions/concepts.
> 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.
> Isn't that what we call 'differential diagnosis'?
> Anyhow. I agree that these DD or reasons for should be seperated and
> clearly distinctable from the 'final' diangosis, preferably based on facts
> and deduction.
> Cheers,
> Stef
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