ID

23547

Beschreibung

Use to record the reason, or reasons, for initiation of any type of healthcare encounter or contact between a healthcare provider and the individual who is the subject of care. The reason may be for clinical, social or administrative purposes. Reason for Encounter is a common phrase used in clinical medicine, however the term is often used in two common ways - one that refers to an administrative category for provision of healthcare and the other that reflects clinical or social problems that motivate individuals to seek healthcare. In an effort to clarify the phrases and intent, this archetype contains two data elements: - The first, 'Contact type', to document the administrative type of healthcare sought or required - for example the type of consultation, emergency care, pre-operative assessment, routine antenatal visit or elective admission. This data element reflects the administrative category of care provision. Use of the phrase 'Contact type', rather than 'Reason for encounter' or 'Reason for visit' reflects the increasing trend towards alternative methods of healthcare provision that may not result in face-to-face contact between the healthcare provider and patient within a consulting room. - The second, 'Presenting problem', to document the clinical reasons for healthcare contact. Chief complaint is regarded as a synonym for 'Presenting problem'. These are intended mainly to capture the patient's perceived issues or symptoms which have triggered them to seek healthcare advice, such as desire to quit smoking, stress, shortness of breath, genetic counselling or abdominal pain. Signs such as impaired conscious state may also be captured here, for example by paramedical staff with an unconscious patient.

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Versionen (1)

1. 08.07.17 08.07.17 - Martin Dugas

Hochgeladen am

8. Juli 2017

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