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Clinical Statement | Entry type | Example archetype | Comments |
Physician: | Observation | There will be an observation since it is a real-world phenomenon that has been observed e.g. by listening. There seems to be an element of 'inference' about it; this is the clinician's assessment of the heart sounds heard to be leaking of blood through the mitral valve of the left side of the heart. | |
| Evaluation | A diagnosis of mitral valve disease may be made; this will usually describe the severity, indicate what studies were done to establish the nature of the disease etc. This is not the same statement as any of the original observations, but would normally summarise them. | |
Patient: | Observation | Anything interesting the patient says may be recorded in the story, depending on the clinician and system. | |
| Evaluation | The clinician may or may not record a 'story'; if his assessment is that the patient is indeed diabetic, he would normally record a diagnosis; this has the same status as any other diagnosis recorded by a clinical professional. | |
Allied health professional: | Observation | Facts about the patient's capabilities in living independently are recorded as Observation(s), and gathered according to a protocol, such as a questionnaire, functional test by occupational therapist etc. How good the information is may depend on the protocol, but in all cases, the result is an observation of various phenomenon in time. | |
| Evaluation | An assessment will be made about the subject based on all the information gathered; some of the evidence might lead to the establishment of a problem of incontinence. |
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