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Re: [Gnumed-devel] clin_health_issue - some thoughts
From: |
J Busser |
Subject: |
Re: [Gnumed-devel] clin_health_issue - some thoughts |
Date: |
Tue, 16 Nov 2004 00:47:18 -0800 |
At 6:40 PM +0100 11/14/04, Karsten Hilbert wrote:
> Is it possible to overhaul the is_aoe/is_rfe/is_active/is_relevant
flag collection so we can make health_issue and episode pure views
on clin_narr?
Yes and no. I don't think we can make them pure views because
they might serve defining purposes beyond the naming.
Is_aoe/is_rfe is encounter related and not immediately a
concern for this step.
I'll try to propose a structure this week that implements the
defines_* fields in clin_narrative thereby consolidating the
is_active/is_clinically_relevant business if no one objects.
snip...
Further discussion welcome.
The following form a "background" over which I planned to further
ruminate on the issue / episode / encounter / diagnosis decisions.
They might be "simple"... I only offer them now in case I am delayed
in making any concrete suggestions.
We want to:
efficiently capture & input info
-> speaks for itself!
be able to re-examine what was found/done at discrete encounters
-> Richard may advise this is not _usual_, yet it may be an important
functionality on an intermittent basis, when having later to rethink /
reconsider / defend the care or actions, IMO - am I alone here?
group any apparent recurrence of clinical items
-> makes it easier to locate individual items
-> permits scrutiny of frequency & time profiles
-> facilitates nesting
nest related items &/or assign importance (clinical_relevance)
-> reflects a decision concerning relationship or importance
-> permits meaningful collapse of data &
-> limits drowning in a sea of information
-> assists more relationships to be observed / inferred
code data, where useful
-> assists communication; analysis; and decision support
avoid logical and clinical inconsistencies
-> less dependence on human compensation for weak design
=====================================
Taking the above together, in assessing patients, we
- identify one or more Purpose(s) (RFEs / Patient requests) for the visit
- collect History / Subjective data that may concern more than one problem
- examine patients and may find abnormalities (or notable normal
findings) in more than one area
- take into account test results and come to an assessment
- make decisions and take action