Sparked Logical Models, published by CSIRO. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/aehrc/logical-model-web/ and changes regularly. See the Directory of published versions

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Logical Model: Problem Diagnosis AUCDI

Official URL: https://aehrc.csiro.au/fhir/logical-models/ProblemDiagnosisAUCDI				Version: 0.0.1
Draft as of 2023-09-11				Computable Name: ProblemDiagnosisAUCDI
Other Identifiers: https://aehrc.csiro.au/id/archetype_id#openEHR-EHR-EVALUATION.problem_diagnosis.v1
Keywords: core

The Problem Diagnosis AUCDI Logical Model Mindmap is shown below.

A summary or overview of a single health condition, injury, disability, or any other issue that impacts the physical, mental and/or social well-being of an individual.

Context

This data group documents a summary or overview of a single active, inactive, or resolved problem or diagnosis, gathered and integrated from various information sources, including multiple consultations and other activities, accumulated, and updated over time. An exception is summary information about a specific pregnancy; a condition that requires a very different data structure.

Traditionally, differentiating between problems and diagnoses has been difficult because they often exist on a continuum, both conceptually and in practice. As clinical evidence accumulates, what begins as a 'problem' may develop into a definitive 'diagnosis.' Adopting a unified data group for both facilitates the collection of clinical evidence and recognises the dynamic and interconnected nature of their relationship.

Use cases include, but are not limited to:

• Recording a diagnosis as the conclusion of a Consultation note,
• A 'Problem List', ‘Medical history’ or similar document, containing one or more ‘Problem/Diagnosis summary’ data groups,
• Triggering clinical decision support related to preventive health and chronic disease management, or
• To exchange critical information about problems or diagnoses with other healthcare providers.

Purpose

To record summary information about a single problem or diagnosis.

Misuse

Not to be used to record summary information about a single pregnancy. The clinical requirements for recording summary details about a pregnancy are quite different to typical problems and diagnoses and therefore out of scope for this data group. It is anticipated that a separate ‘Pregnancy summary’ data group will be proposed for future releases of AUCDI. Note: problems or diagnoses identified during the pregnancy or as direct complications of the pregnancy may be added using this data group – for example, ‘Gestational diabetes’, ‘Pre-eclampsia’ or ‘Urinary tract infection’.

Considerations

Both problems or diagnoses can be recorded using this same data model without distinguishing and labelling them as one or the other. The recording pattern is closely aligned, and what may initially be considered a ‘soft’ problem may evolve towards a formal diagnosis as more clinical evidence is discovered.

In future updates, it is anticipated this data group will be extended to incorporate additional detail.

Roadmap

The openEHR ‘Problem/Diagnosis’ archetype and the FHIR ‘Condition’ resource are mature information models that have been used globally in a broad range of implementations over many years. They form the basis for this initial AUCDI R1 data group and provide guidance for potential future augmentation.

In addition, the 'Problem/Diagnosis name' value set can be extended to include problems identified from an allied health or Social Determinants of Health (SDOH) perspective, such as 'Food insecurity' and 'Financial insecurity'.

The mind map below demonstrates a proposed roadmap for developing the ‘Problem/Diagnosis summary’ data group based on the published openEHR ‘Problem/Diagnosis’ archetype.

Potential candidate data elements for Release 2:

• Date/Time clinically recognised – this equates to the ‘Date of diagnosis’ for a formal diagnosis but is deliberately framed more loosely to support a date related to a softer problem.
• Last updated – the timestamp indicates whether the information is current or outdated, serving as a critical marker of its timeliness.

Usage:

• This Logical Model Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

 

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