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Sergio 18/12/2007
In our environment, either primary care or hospital setting, we use "motivo de consulta" which would translate as chief complaint. I must confess I can't see why the scope is different (the patient is in pain or has a symptom that makes him go to the primary care unit or ER) but this is my point of view only. I think that it would serve our purposes best to have one archetype with different label, the main objective is the same, to register what motivated the patient to seek help in the first place, I think different archetypes might lead to duplicate information in the future.
I'd like to know the opinion of the rest of the team, my point of view is based on our health system, it might be inadequate for someone else's.
Here in Brazil we register the to different concepts with two different domains ( for primary care, and as we call - "pronto-atendimento_ - sort of outpatient emergency not for very serious cases Reason for encounter - we use ICD-10 chapter Z Chief Complain - as part of the patient history - so far is being recorded as text - we're considering perhaps ICPC in Portuguese but text is OK for now Check-list conditions and diagnosis - ICD-10 (mandatory in the country).
We already made those constraints in the archetypes we translated.
Ian 18/12/2007
There is no doubt in my mind that these are exactly the same thing and do not require separate archetypes. This is a simple statement/encapsulation of why the patient/ client has asked for assistance. I would argue that it could equally apply over any possible professional encounter, completely outwith the clinical domain e.g. lawyer, archetype.
The value is in briefly describing the patient's understanding as they seek advice. I am not sure how much semantic validity or value that might have. In my practice, which was heavily POMR orientated we wrote a simple phrase in the right hand margin to try to capture the overall nature of the consultation which may have included both the clinician and patient perspective.
Sure the scope my vary by speciality but so may that for 'diagnosis'. In a sense 'presenting complaint' is the patient's 'diagnosis'. If the purpose of the archetype is clearly generic with examples given in the use and misuse, could the renaming of the node just be left to the template, without the need for a choice of terms.