Stream: Orders and Observation WG
Topic: Observations with an interpretation and no value
Grahame Grieve (Sep 14 2018 at 00:55):
Does OO have any guidance anywhere about when you would have an observation that has a coded value, and whether to put the code in the value or the interpretation?
Grahame Grieve (Sep 14 2018 at 00:55):
obviously, if the observation code is 'femur length', and the code is 'longer than normal', that's an interpretation whether or not you have an actual value
Grahame Grieve (Sep 14 2018 at 00:56):
but if the observation is 'hip mobility concern' with values ok, watch, refer for treatment -is that a value or an interpretation?
Grahame Grieve (Sep 14 2018 at 00:57):
@Reuben Daniels @Nichol Hill @Vincent McCauley feel free to chime in with other examples
Grahame Grieve (Sep 14 2018 at 00:57):
(from Australian child health standards meeting)
Nichol Hill (Sep 14 2018 at 01:10):
Thanks Grahame. This encapsulates well.
In context the observations are part of the set of assessment that are performed at child health checks (eyes, hips, fontanalles).
Also would be good to understand how this normalises with other assesments taken as part of the same set such as weight that record both the actual weight and a value of ok, watch, refer for treatment
Rob Hausam (Sep 14 2018 at 16:35):
I think we haven't been particularly specific or prescriptive regarding the rules around this. My personal take at the moment (which may or may not be consistent with the views of others in OO) would be to avoid a proliferation of very specific interpretation codes. For 'femur length' I think you would ideally provide the actual measurement value, but a code that categorizes it as "longer that normal" (with maybe better wording) could be defined and used instead, if that's really desired. In that case I think I would still use one of the currently defined interpretation codes - probably 'H' (High), since it's "above the upper limit of the reference range".
Rob Hausam (Sep 14 2018 at 16:42):
For 'hip mobility concern' I'm not sure if 'ok', 'watch' and 'refer for treatment' would necessarily be the best set of values (or interpretations) - that could b e discussed. But I would be inclined to follow the same or similar pattern as with 'femur length'.
Eric Haas (Sep 18 2018 at 16:22):
I imagine that the current situation is that a measurement is given and then a long narrative text blob is provided in the comments sections providing all this interpretative information. Also in my mind -'ok', 'watch' and 'refer for treatment' are not interpretations but Clinical Assessments.
Last updated: Apr 12 2022 at 19:14 UTC
