Sam Heard 17/12/07
Dear All
We have a decision to make. When people come to hospital a doctor will usually record the "Chief complaint" or "Presenting complaint". In primary care the "Reason for encounter" is recorded. As these are simple meta-observations and are best suited to be evaluations - no date information, no qualifiers - the point is to keep the data very clean. The question is - should these be different archetypes or the same archetype with different labels for purpose. There is no doubt that their scope is different when we think of inpatient presentation compared with primary care - but it is possible to think of almost every situation in the continuum so that they do merge. We could have a label for the node that allowed the choice of Reason for encounter OR Chief complaint OR Presenting complaint - and leave the terminology binding to the template. The advantage is that in every language we would have up to three conventions.
Retrieving this data from different situations would be simplified - one place to look. We could even use an item_single so the concept could not be extended. This would ensure it was used for summary data.What do others think?
Sergio 18/12/2007would 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.
Sergio