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Re: [Gnumed-devel] Turtorials

From: Eric MAEKER
Subject: Re: [Gnumed-devel] Turtorials
Date: Sun, 4 Jul 2010 21:15:47 +0200

Le 4 juil. 2010 à 20:50, Karsten Hilbert <address@hidden> a écrit :

On Sat, Jul 03, 2010 at 12:12:14PM +0200, Hilbert, Sebastian wrote:

so we can start to think on How Tos for these issues.

Good idea. While one would think that the concept is trivial its
implementation in GNUmed *might* need a how-to description.

I really like the idea of clinical how to's. If those were
video that'd be perfect   *evil grin*

- second this facilitates the job of doctors while browsing the EMR - besides, acute diagnostics generally aren´t supposed to be that precise ...

Hmm. Isn't a diagnosis always precise. It might be uncertain or wrong but always precise. Everything else is findings instead of diagnosis I guess.

While it is correct that a diagnosis is precise by
definition we (in primary care) do not actually find the
diagnosis of the current complaint in many patients (also,
many times there will not really be one as the chief
complaint is a Befindlichkeitsstörung rather than true

What Rogerio is likely referring to is what we already
formalized as

A "Sign"
B "Cluster of signs"
C "Syndromic diagnosis"
D "Scientific diagnosis"

SOAP is the key ! It is fully i18n and understand by all practitioner.
S subjective
O objective
A assessment
P plan

IOW, we don't just realize that we don't know. We even let
the GP formalize their level of confidence. That's riding
the edge of primary care research.

Rogerio's point was the acute afflictions are far more
likely to be A or B while chronic conditions should really
be sought be become D.

This is also what Jim previously suggested as a database
report suitable for raising clinical excellence: Find
chronic (in today's GNUmed terms: =
True and clin.health_issue.known_since = <quite_long>) which
are clin.health_issue.diagnostic_certainty in (ABC).

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