Printer Friendly, PDF & Email

Problems

Information about a condition, diagnosis, or other event, situation, issue, or clinical concept that is documented.

Data Element

Additional Information

Date of Diagnosis
A date field associated with each diagnosis on a patients problem list and/or medical diagnosis history to capture the date a patient first had the diagnosis. One could imagine, in the future, supplementing this with additional data elements for capturing identifying information for the individual making this determination, their role (physician vs. other healthcare professional, etc.), institution, some categorization of the basis for the determination (symptoms, signs, laboratory abnormality, etc.)

Comment

As noted elsewhere, …

As noted elsewhere, “diagnosis” needs to be better defined. For instance, will ONC allow more than one diagnosis to be reported? A physician may diagnose a patient with X, Y, and Z; the patient then sees a physical therapist, and the physical therapist identifies several musculoskeletal diagnoses. In this instance, are all diagnoses reported including all co-morbidities? We also suggest that ONC clarify that more than one clinician is eligible to populate this field. ONC also should clarify how comorbidities should be tracked and whether these diagnoses/conditions are reported. Finally, we suggest that ONC address how “errors” will be resolved, for instance, when the date of diagnosis may vary between the date of diagnosis in an EHR and the date that the patient reports that they were diagnosed.

Log in or register to post comments