Condition Tracking

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Concern Tracking (AKA Condition Tracking)

The Concern tracking structure helps to track threads of related observation over time. It's primary use case is for following patient diagnoses or conditions, although it is also used for Allergies and could be used tracking medications or other patient history.

Example Use Case

The need for such a structure is demonstrated by the following use use case:

• Day 1 9am -- A patient, John Smith with multiple medical problems including Diabetes and hypertension develops "chest pain"
• Day 1 10am -- Mr. Smith presents to the ER. His chest pain has resolved, but is still concerned. He is triaged with a chief complaint of "chest pain"
• Day 1 11am -- Mr Smith is noted to have a changes on his EKG -- his ER physician admits with a diagnosis of "r/o MI"
• Day 2 8am -- Mr. Smiths subsequent EKG's and labs return normal. HIs Primary care physician makes lists the diagnosis as "probable GERD" and discharges the patient with instructions to follow-up with a gastroenterologist.
• Day 8 11am -- Mr. Smith follows up with the gastroenterologist and an EGD is performed. Mr. Smith is noted to have "Barretts Esophagus."

In this case, the observations "chest pain" "r/o MI", "probable GERD", and "Barretts" are related via a common thread of a "concern" that a physician might have if following that patient. This concern is subjectively separate and distinct from other processes being followed for the patient such as Mr. Smiths Hypertension and Diabetes.

HL7 Model (DSTU status)

Concern Tracking RM000300UV

Historical Discussions

• Discussion on Condition Tracking portion of the May 2006 Ballot
• Discussion on Types of Updates