hi Ian (and others)
I spent some time today working on the imaging exam
archetype with Heather. We had some questions about
the Finding Details section, and Heather thought that
you are responsible for this part. And that part certainly
leaves me confused.
There is a part called Detailed findings. In it, there is
Finding name: Text
The name of the finding e.g Chest, heart or bones for a Chest x-ray.
Finding: Text
Brief description, often coded, of an individual finding from an
imaging procedure e.g. '2cm node in left upper lobe'.
Finding description: Text
A narrative, detailed description of each individual finding
(note for other readers, this version of the archetype is
in preparation, and isn't posted to the CKM)
I don't know what the intent is here. Howe do you differentiate
between these, and know
how to use them consistently?
In fact, I wasn't exactly sure what "detailed findings" is exactly
meant to be - the
term isn't really defined. I assumed it was for some structured
representation of
the contents of the narrative, presumably to support some kind of synoptic
reporting? I'd add at least a Finding Value : ANY so that proper synoptic
reports would be possible.
Heather and I thought that some examples might help have a productive
discussion.
This is some of the things I thought might be useful to say in a coded way
using snomed + values
LMP: [value in months]
size of (uterus, placenta, foetus): [value in mm]
[Snomed Concept 84138006: Collapse of vertebra]
246120007: Nodule size = [20mm]
422005008: Ferucarbotran (product)
That'll probably do to start us off. If no one claims reponsibility or
defends this
model, I'll suggest that we have just code | value following the classic HL7
model. It's certainly got it's problems, but at least they are well understood,
and the openEHR model would match the HL7 v2/v3 models of the same
Grahame
p.s. I tried to code exactly "2cm node in left upper lobe", but snomed
isn't vague
in those ways