Diagnosis

Diagnosis Topic

Note: this is a cross cutting concern which impacts many HL7 groups, and needs to be reviewed and vetted by SDWG, PCWG, ECWG, CIC and TermInfo.

Process

• Final Objective
  • Balloted specification(s) may be considered
    • What Realm?
    • DSTU v. Normative v. Informative?
• How to Get there
  • Participate in discussions during conference calls
    • Document input on this wiki
  • Working directly on wiki
    • Discussion v. wiki page: please confine discussion to discussion page. This page should be considered the "in progress draft" of something we can send to ballot.
    • Terminology / vocabulary.
      • Help track down all the relevant codes which identity a "type" of diagnosis (not the diagnosis itself) would be very helpful.
      • We need to define a value set we can safely use without ambiguity across domains and use cases
• Model of meaning v. model of use
  • This is where a lot of the complexity is. We need to define the different use cases, as well as how to define models which work for them such that they have a singular model of meaning

Diagnosis Definition is Contextual

The term diagnosis, derived from the Greek term διάγνωσις (discernment), has context dependent meanings. As such, use will require formal definitions so it can be properly treated algorithmically. It is often defined as the art or act of identifying a disease from its signs and symptoms as well as the conclusion reached. (Merriam Webster). Often diagnosis is further divided based upon source of knowledge, e.g. in cancer there is a concept of the “tissue diagnosis” (the type of cancer as identified from an examination of biopsy material).

There is also a distinction made by some between the “clinical diagnosis”, i.e. the diagnosis which is determined by history and physical exam, “radiologic diagnosis” (e.g. the discovery of pathognomonic features in a diagnostic imaging procedure, “medical diagnosis” (the diagnosis by a physician) and nursing diagnosis (the concept of diagnosis used by nurses).

Medical Diagnosis

The medical diagnosis attributes a causative pathologic or physiologic process to a given set of clinical findings. Medical diagnosis typically involves multiple modes of investigation. It usually is predicated upon a history of the presenting problem, a review of systems (symptoms specific for different organ systems), a physical examination

Nursing Diagnosis

The text below comes form http://www.nanda.org/DiagnosisDevelopment/DiagnosisSubmission/PreparingYourSubmission/GlossaryofTerms.aspx (obtain on 07-03-2011)

is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability' (NANDA, 2009).

Actual Nursing Diagnosis

A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community.

Health-Promotion Nursing Diagnosis

A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.

Risk Nursing Diagnosis

Describes human responses to health conditions / life processes that may develop in a vulnerable individual / family / community. It is supported by risk factors that contribute to increased vulnerability.

Syndrome

A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.

From ANA, http://www.nursingworld.org/EspeciallyForYou/StudentNurses/Thenursingprocess.aspx, obtain on 07-03-2011.

The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

From ISO 18104. Draft: Health Informatics: Categorial structures for representation of nursing diagnoses and nursing actions in terminological systems Revision of ISO 18104 Health Informatics: Integration of a reference terminology model for nursing

For the purposes of this International Standard, a nursing diagnosis shall be expressed either as a judgement (6.2.3) on a focus (6.2.2) or as a single clinical finding (6.2.1) concept representing an altered state, process, structure, function behaviour or other state observed about a subject of care. Examples of the first type of expression include: impaired mobility, inadequate nutrition and knowledge deficit. Examples of the second type of expression include: wound, nausea, pain, depression.

A nursing diagnosis may have an associated potential (6.3.6) which indicates that there is a risk for or chance for a nursing diagnosis, for example, risk for depression, chance for weight reduction, risk for altered skin integrity.

A nursing diagnosis may also be associated with a subject of information (6.3.8) other than the subject of the record, for example, caregiver stress, impaired parental coping.

A nursing diagnosis may be qualified by degree (6.3.2) (scale of gradations), clinical course (6.3.1) (course and or onset) and timing (6.3.9) (an occurrence or a point or period in time).

Components of a Nursing Diagnosis

The text below comes form http://www.nanda.org/DiagnosisDevelopment/DiagnosisSubmission/PreparingYourSubmission/GlossaryofTerms.aspx (obtain on 07-03-2011)

Label

Provides a name for a diagnosis. It is a concise term or phrase that represents a pattern of related clues. It may include modifiers.

Definition

Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses.

Defining Characteristics

Observable clues / inferences that cluster as manifestations of an actual or wellness nursing diagnosis.

Risk Factors

Environmental factors and physiological, psychological, genetic or chemical elements that increase the vulnerability of an individual, family or community to an unhealthful event.

Related Factors

Factors that appear to show some type of patterned relationship with the nursing diagnosis. Such factors may be described as antecedent to, associated with, related to, contributing to or abetting. Only actual nursing diagnoses have related factors.

Differential Diagnosis (q.v. LOINC 56865-9)

A differential diagnosis is a set of

Admission (or Admitting) Diagnosis

Admission Diagnosis is:

• a medical diagnosis
• made during an in-patient admission process
• used as the basis for continuing patient assessment, planning, and care
• used as the justification for insurance claim for the in-patient admission

Salient Features

Certainty and Uncertainty

All diagnosis are associated with a non-zero probability of being wrong. While many diagnosis approximate zero, there are always possibilities of laboratory error, mix-up of specimens, errors on the part of any of the healthcare team (particularly radiologists and pathologists, upon whom great importance is placed for accuracy). This is typically most evident with clinical diagnosis.

Associations between diagnosis and other key elements of an EHR, health history summary, PHR, or other HIT.

Changes in Diagnosis

Often a patient’s diagnosis changes. This can be due to diagnostic error, error in recording or codeing the diagnosis, error introduced by use of ICD codes from billing systems, further information becoming available which further defines or corrects a diagnosis, and progression of disease.