Diagnosis Recording SIG
The Diagnosis Recording SIG will discuss the diagnoses issues in depth and explore pathways to improvement in collaboration with other organisations.
Well-structured, accurate records of patient problems and diagnoses are essential for high quality clinical care and research, and advances such as precision medicine and Artificial Intelligence. Better recording requires careful consideration of information models, interoperability, standardisation, terminologies, user interfaces and data sharing.
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Please note, the Chair and presenters are responsible for the content and views expressed in the webinar.
26 November 2020
Diagnosis Recording Special Interest Group Webinar
This meeting was Chaired by Dr Anoop Shah (Clinical Lecturer, UCL Institute of Health Informatics, THIS Institute Postdoctoral Fellow, Fellow of the FCI) & Maggie Lay (FCI Council Member, Clinical Safety Officer & Clinical Informatics Lead at South Central and West CSU).
For medical diagnoses, many of the issues have already been raised in a previous project by the Professional Record Standards Body at the Royal College of Physicians. We aim to build on this and produce a position paper with recommendations for improving electronic health record systems.
However, while there may be a broad agreement about what the term “diagnosis” means between primary and secondary medical care, there is considerable difference in how the term “problem” is used in each medical record. In the wider patient and health and care context, the differences in terminology use make it arguably unsafe to transliterate those terms to electronic records. We propose to have a broader discussion to develop a common lexicon around diagnoses and problems, and a better understanding of the information needs of different professional groups.