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?
Sam Heard 17/12/07
- 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.
- Sebastian 18/12/2007
I agree, this should be done in the same archetype, much like diagnoses wouldn't be in different archetypes even if setting/scope etc. is different.- Beatriz 18/12/2007
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.
- Beatriz 18/12/2007
- Sebastian 18/12/2007
- 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. - Omer 18/12/2007
"Chief Complaint" is the most common expectation here in Turkey. Reason for Encounter is mostly understood as patient admission way (i.e.: emergency, scheduled exam, routine-checkup, control, etc...). Also, most of the insurance companies have a main field of "Chief/Main Complaint" along with it's "Duration or Since When". I believe, having a simple and to the point archetype with only Chief_Complaint field (allowing the use of, most likely, ICD-10x) and Duration field would be very handy.