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[Gnumed-devel] need assessment from fellow clinicians

From: Karsten Hilbert
Subject: [Gnumed-devel] need assessment from fellow clinicians
Date: Wed, 30 Jun 2004 02:00:12 +0200
User-agent: Mutt/

Hi all,

I have been thinking on how to best get the wildly overlapping
concepts of "Assessment" (soAp), "active problem" (aP), and
"diagnosis" (Dx) (medical, not billing) under control and
aligned. I think I have come up with a plan but need feedback.

We probably all agree upon the fact that in primary care there
is the useful concept of Reason for Encounter (Reason Visit
Care, for them Americans) - RFE (German "Beratungsanla├č").

soAp can be anything from "Borreliosis - positive serology"
(hard-n-fast diagnosis) to "acute abdomen, seriously ill,
requiring investigation" (rather vague - but still useful ! -
narrated assessment).

Dx *should* be a well-established medical diagnosis.

aP can be any of the above. The difference to soAp would be
that aP does not contain explanatory statements but rather
treats free-text assessments as if they were diagnosis (eg.
"acute abdomen").

German literature on the subject talks about a
"Beratungsergebnis" - the verbalized outcome of an encounter
as agreed upon by patient and provider. I think this captures
all of the above quite well and we would call it "Assessment
of Encounter" - AOE.

Now, how would we relate the AOE to other concepts ?

- Each encounter may have several RFEs.
- Each episode may have several successively refined RFEs some
  of which may simply be "followup *" where * is the RFE of
  the previous encounter. (Should this be free text or do we
  allow for a is_followup::boolean field in the tables ?)
- The latest AOE per episode is regarded an aP. AOEs may be
  tagged "permanently relevant" such that they stay listed as
  aPs even when their episode is no longer active (what that
  means, semantically, needs to be investigated, perhaps a
  timeout will do).
- There should be exactly one AOE per episode-encounter-combo,
  eg each episode touched in an encounter should have *one* AOE
  (there may be several RFEs, though per episode-encounter-combo).
- "coded_diagnosis" rows may link to AOEs which makes them a
  diagnosis should any code care to look at the link between the
  two. Another option would be to have a field "certainty"
  right in the AOE table -- if we can agree upon a
  classification. The German literature talks about "symptom",
  "group-of-symptoms", "syndrome", and "diagnosis". I am fine
  with this but I realize this may be debatable in other

So, in conclusion, soAp is the narrated case assessment per
encounter. An AOE is the gist thereof in one catchy phrase. aP
is the latest-and-greatest of them AOEs across all encounters
per one episode. Dx is likely to appear as one of the last
AOEs per episode if and when a scientific medical diagnosis
has been established.


Does that make sense ?

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