Working Group - Diagnostic Study

Unique Agenda Items

1) Diagnostic study type of documentation

2) Isabelle's ontology

Diagnostic Study

• There are many definitions of documents that document a procedure on a patient to collect data, hold the data, or analyze the data.  Some are research-focused, some are radiology-focused, and some are wide open.   Some take an 'intention' approach to the definition (i.e. we intend the colonoscopy to be just collecting data, but then we did a little procedure, but we'll call it a diagnostic study). We need a definition that is about what the author of the document put in the document.  It needs to be distinct from the Procedure definition to keep so that they do not overlap: any given document should fit one or the other, never both, so that every implementer codes the same document the same way.
• We choose to code a document as a procedure when the author writes mostly about what they did to the patient.  We then code the document as a diagnostic study when most of the text is about interpreting the results.   
• Radiology, Pathology and Lab has its own coding for reports so they are not considered in our document ontology
• We will only use the SMD axis with the Type = Diagnostic Service.  The SMD will be the clinical domain of the document's contents, not the authors credentials.  
• We need to make a list of specific tests and what SMD they are assigned
• We believe that Document Kind should = Report.  However, current LOINC codes use 'Note'.  We will ask for a change or change it for Canada.  
• The display name for Diagnostic Study will be "Diagnostic Report".  
• We encourage hospitals to use procedure or investigation code systems and include the assigned code and display name in the file metadata.  Some options are SNOMED, CCI, ICHI, CPT4
• We might provide some test-specific DO codes if needed for high frequency reports
• 
  

Modified Concept Creation Guide for ToS = Diagnostic Study

Vote

MB: 5

DS: 5

DL: 5

DC: 5

NS: 5

Ml:5

IBek:5

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