Revision of the initial evaluation record at a later date:
Problem/diagnosis name: COVID
Diagnostic certainty: Confirmed
Clinical evidence CLUSTER nested in ‘Specific details’ SLOT: points to COVID test result
This reflects the diagnosis changing but using the same record structure and revisions will prevent multiple potentially conflicting/redundant diagnoses and support documentation of the evolution. UI/business logic may be needed to support making this change visible to the clinician.
All the evolving clinical notes can be associated with the same instance of Problem/Diagnosis
Yes, I looked at that too. It supports labels of ‘Preliminary/Working/Established’ diagnoses, which implies a slightly different way of recording certainty.
Hi Heather,
Thank you very much for your answer !!
I think it will work for us !!
Just to be sure I understand the solution you exposed. We are talking about VERSIONING. Correct me if I am wrong.
We will probably test how the AQL respond on this case.
This solution though, makes us wonder if we should ADJUST some POINTS on our strategy on how we manage CLINICAL NOTES and related DIAGNOSES.
The thing is that we will have to use a 2 TEMPLATES strategy on the same information system. One for the DIAGNOSIS (full and detailed information), and one for the CLINICAL NOTES (where the diagnosis is only mentioned as a reference to the other Template).
If it helps here I share the link to the topic, where I explained the 2 Templates approach we initially plan.
MY CONCERN IS:
In the template where we Store the CLINICAL notes … ¿ would the diagnosis on the CONTEXT-CLUSTER (Clinical Context) still work in order to relate to the DIAGNOSIS Template?
¿ Or should we use the same archetype Problem/Diagnosis instead of the Cluster Clinical context ? Even if it only contains name and date of the problem, and the full information of the problem is persisted in the other Template.
I am aware, that this related question is a little bit messy, and I may not have explained in a clearly and understandable way. If there is something I can do to clarify the matter, I’ll be glad to reformulate.
I share the 2 TEMPLATES. The Clinical Notes one and the Diagnosis one. I hope this helps to understand this related question.
When we built a Norwegian GP system on openEHR, we adopted an approach much more like yours. This was largely based on the experience of UK GP systems where they very largely separate the idea of an ‘Encounter Diagnosis’ from a maintained and hierarchical ‘Problem list’ and it is the ‘Problem List’ that is the source of truth for decision support and further processing.
This is also close to the Contsys idea of Problem threads , that I tried to replicate in openEHR (never tried out) .
Heather’s suggestion is absolutely correct where a previous diagnosis is clearly wrong or misleading, particularly over a short term period of illness and with the evolution from suspected->Confirmed but a separately curated problem list possibly works better over a longer timespan.
However, it is considerably more challenging to handle technically, and more importantly, does require quite intensive clinical input and ongoing curation, to ensure that the ongoing stream of ‘encounter diagnoses’ are correctly inked into the problem list, or de-linked/rearranged if for example a series of ‘wheezy bronchitis’ episodes in a small child turn out to be asthma. I don’t think this means that the original diagnoses were ‘wrong’, just that the overall picture has evolved.
If you did go down the separate Problem list approach, I’d certainly use the same archetype in both templates, but (mostly) ensure that the problem list was the source of truth for decision support etc. (see caveats above).
‘Suspected’ vs ‘Definite’ Working vs Final etc is a whole other tricky area. When we developed that problem _qualifier archetype we were aware that this is a whole other area that is very messy in current records and where different clinicians will have very different interpretations. As we really get into federated querying, I suspect we are getting close to having to get some clinical consensus, which will not be at all easy. In particular how to handle ‘suspected’ vs. ‘confirmed’.
‘Suspected’ is particularly problematic e.g if as a GP, I get a discharge letter with a code of ‘Suspected DVT’, does that mean that I should treat this patient as if they had a proven DVT or not.