Screening questionnaire archetypes or Physical examination findings

Clinical
1

For the modelling of templates for a (status) report we are unsure about which archetypes to use. The report consists of many individual findings/symptoms, most of them only recorded as present/absent. So far, we have mostly modelled them using the generic Physical examination findings archetype(s). Now we are considering using the Symptom/sign screening questionnaire instead, as the structure and elements match our requirements well. However, we have some concerns regarding correct usage. Are the Screening questionnaire archetypes specifically meant for questions directed at the patient, or can it be extended to this use case for recording simple present/absent data?

2

Hi Jonas,

If you wish to very simply record whether a predetermined list of symptoms are present, absent or unknown/unsure, I’d recommend using the Symptom/sign screening questionnaire archetype. However, it depends a bit on the actual context of the clinical situation. If the context is the clinician actually examining the patient and recording findings, the Physical examination findings is probably more appropriate.

3

Hi Silje, thanks for your answer!
So we do have a long predetermined list of symptoms, with the answers being recorded by a clinician screening for those. From your answer I am still unsure how to go forward, as I still feel that both options kind of fit, but it is neither a “proper“ physical examination or a questionnaire (but rather a screening). Do you feel that using Symptom/sign screening questionnaire instead of Physical examination findings is justifiable, despite it being simply a list of symptoms without specific questions attached? We are leaning towards that option, as it would simplify and decrease the work for the various similar reports we will need to model.

4
  1. Does the clinician ask the patient “do you have this or that symptom?”, or do they examine them?
  2. Are yes/no(/unsure/unknown) responses a necessary part of the data you wish to record, or would the presence or absence (and potentially much more details) of specific findings on examination fit better with your requirements?
5
  1. The clinician does not ask the patient, it’s a brief examination (screening) for signs in a status on admission report consisting of 100+ elements
  2. most signs are recorded as present/absent, some of them consist of a small list of possible values, for example:

General state of health: Good / poor / poor due to pain
Oriented to time: Yes / no / partially
Sensibility upper extremity left: Normal / pathological

6

To me this looks like variations of “Clinical interpretation” in the CLUSTER.exam archetype.