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Background

Any self-respecting medical record system needs to be able to track patient conditions (what is often called the patient's "Problem List").  We have chosen "Condition" instead of "Problem" to align with contemporary thinking (e.g., since "Pregnancy" isn't really a "Problem" for most people).

Definitions

  • Chief Complaint – the reason the patient is seeking care, typically given as a symptom and duration (e.g., "Fever ⨉ 5 days"), but is sometimes given as an existing diagnosis for scheduled or routine visits (e.g., a patient coming to clinic for a scheduled iron injection to treat anemia might have the diagnosis "Iron-Deficiency Anemia" recorded as a chief complaint).
     
  • Condition – a symptom (something the patient has noticed), a finding (something that has been observed about the patient), or a diagnosis (clinical syndrome diagnosed through observation or testing)
     
  • Condition List – a longitudinal list of conditions that are relevant to the patient's health status, typically populated with chronic or recurring medical conditions (e.g., "Hypertension" or "Diabetes Mellitus") or prior conditions that continue to affect health care decisions for the patient (e.g., "History of Stroke" or "History of Breast Cancer")
     
  • Diagnosis – a condition pertaining to a particular encounter (e.g., one of the reasons that patient is being seen today)
     
  • Diagnosis List – a list of diagnoses pertaining to a particular encounter (i.e., the reasons that the patient was seen today or the list of diagnoses addressed during the clinical transaction)
     
  • Finding – something objective found physical exam or through testing (e.g., "Murmur" or "Expiratory Wheezes")
      
  • Symptom – something subjective the patient has noted and is not typically observed by physical exam (e.g., "Headache", "Fatigue", or "Wrist Pain")
     
  • Symptom/Finding –  some things can be noted by the patient as well as observed on physical exam (e.g., "Fever", "Rash", or "Weakness")

Design Ideas

Condition

  • Patient
  • Status/Modifier - History Of, Presumed (or Provisional), Confirmed
    • FHIR condition status is provisional, working, confirmed, refuted. But we don't want to include refuted conditions here
      • We propose that the best-practice approach of recording "today, I ruled out TB" is to record this as an observation during an encounter/visit, rather than a "refuted condition"
  • Concept (symptom or diagnosis, e.g. "Chest Pain" or "Pneumonia")
    • Should we allow free text answers? Yes. (But this is not best practice, and it's really best to avoid this if an implementation can. And we'd want a toggle that lets an implementation say it does not allow free-text answers.)
  • OnsetDate
  • Codes (0-to-n reference terms) <- Don't these come from the concept? Or is this something different?
    • Typically used for billing (e.g., ICD codes)
  • AdditionalDetail (String)
  • DateCreated
  • CreatedBy
  • Voided
  • VoidedBy
  • VoidReason

Condition List

  • 0-to-n Conditions assigned to a patient

  • You should have to explicitly ask for historical (voided) items

Diagnosis List

  • 0-to-n Conditions associated with an Encounter

See Also

 

 

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