ID

23545

Descrição

Use for recording details about a single, identified health problem or diagnosis. Clear definitions that enable differentiation between a 'problem' and a 'diagnosis' are almost impossible in practice - we cannot reliably tell when a problem should be regarded as a diagnosis. When diagnostic or classification criteria are successfully met, then we can confidently call the condition a formal diagnosis, but prior to these conditions being met and while there is supportive evidence available, it can also be valid to use the term 'diagnosis'. The amount of supportive evidence required for the label of diagnosis is not easy to define and in reality probably varies from condition to condition. Many standards committees have grappled with this definitional conundrum for years without clear resolution. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'. In this archetype it is not neccessary to classify the condition as a 'problem' or 'diagnosis'. The data requirements to support documentation of either are identical, with additional data structure required to support inclusion of the evidence if and when it becomes available. Examples of problems include: the individual's expressed desire to lose weight, but without a formal diagnosis of Obesity; or a relationship problem with a family member. Examples of formal diagnoses would include a cancer that is supported by historical information, examination findings, histopathological findings, radiological findings and meets all requirements for known diagnostic criteria. In practice, most problems or diagnoses do not sit at either end of the problem-diagnosis spectrum, but somewhere in between. This archetype can be used within many contexts. For example, recording a problem or a clinical diagnosis during a clinical consultation; populating a persistent Problem List; or to provide a summary statement within a Discharge Summary document. In practice, clinicians use many context-specific qualifiers such as past/present, primary/secondary, active/inactive, admission/discharge etc. The contexts can be location-, specialisation-, episode- or workflow-specific, and these can cause confusion or even potential safety issues if perpetuated in Problem Lists or shared in documents that are outside of the original context. These qualifiers can be archetyped separately and included in the ‘Status’ slot, because their use varies in different settings. It is expected that these will be used mostly within the appropriate context and not shared out of that context without clear understanding of potential consequences. For example, a primary diagnosis to one clinician may be a secondary one to another specialist; an active problem can become inactive (or vice versa) and this can impact the safe use of clinical decision support. In general these qualifiers should be applied locally within the context of the clinical system, and in practice these statuses should be manually curated by clinicians to ensure that lists of Current/Past, Active/Inactive or Primary/Secondary Problems are clinically accurate. This archetype will be used as a component within the Problem Oriented Medical Record as described by Larry Weed. Additional archetypes, representing clinical concepts such as condition as an overarching organiser for diagnoses etc, will need to be developed to support this approach. In some situations, it may be assumed that identification of a diagnosis fits only within the expertise of physicians, but this is not the intent for this archetype. Diagnoses can be recorded using this archetype by any healthcare professional.

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Versões (2)

1. 08/07/2017 08/07/2017 - Martin Dugas
2. 08/07/2017 08/07/2017 - Martin Dugas

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8 de julho de 2017

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