CCTOS Common : Health Issues, Problems

• Objectives:
• A health issue is here an assessment about a set of raw information, maybe a problem to be further analyzed or maybe a proven diagnosis to be treated.
• Support of collaborative work:
• Team work require the availability of a synthesis, all partners of the care team  could understand.   From the point of view of the continuity of care, this synthesis should be maintained up to date, available for any new care provider at any time.
• Quality of care:
• Forcing people to write explicitly what they think about the available facts, is on itself a factor of quality.  different actors could have a different understanding about the same observed facts and are responsible of their opinions.
• Educational value:
• Beginners need to learn not only a lot of theoretical knowledge, but also a methodology to manage complex medical information in the scope of a multidisciplinary team.
• Summary:
• Derived from Medical Data and adding the following aspects.
• Introduction:
• The recommended way to maintain a global synthesis is a problem list, according to the principle of the "POMR", the Problem Oriented Medical Record of Prof L WEED.
• One has to look at one Health Issue at a time, i.e. at all issues which are not "normal" and/or which require further attention.
• It must also be possible to record an assessment about the absence of a problem, when it has been evaluated and found normal.  This is of particular importance for the nursing and for health screening plans (see below).
• For every health issue:
• Attribute of an issue could be :
• "not yet understood problem":  e.g. infectious syndrome, back pain, ...  when more investigations are necessary.
• "proved diagnosis", when the demand is a treatment.
• "risk factors": e.g. allergy to aspirin, generic risk factors in a given population group, which are the motivation for vaccinations and health screening procedures.
• "past history": closed Health Issues, which could still have consequences, invalidity, or risk of recurrence.
• Version of the health issue, because health issues have usually an evolution through several versions, for example from reason for encounter, preliminary syndrome, to a confirmed diagnose.
• Description of the the health issue:
• Description of the problem, i.e. what is known up to now, e.g. infectious syndrome.
• Optional attributes as degree of certitude, degree of severity, ...
• Optional classification(s), if statistics are required.
• Links to related information:
• Links to the facts having motivated the assessment of the health issue, e.g. fever, leucocytosis, ...
• Links to actions taken in function of the problems, e.g. more tests, X rays, prescription, ...
• Links to additional comments and considered work hypothesis.
• Links to guidelines and recommendations, as far as the problem is well identified and as far as guidelines are available.
• A patient may have many health issues at the same time, particularly the elderly patients.  
• Although one of the issue could be at the foreground, a doctor should always be aware of all issues.
• Different care providers could make different assessments about the same set of observed facts. The name of the author of the assessment must always be visible.  Several points of views can be useful to record, coming from several doctors, from a nurse, from the patient himself.
  The reader of the information will have to make his mind, in function of his own judgment and the degree of trust he has in the the authors of different points of view.
• A good dictionary of Health Issues does not yet seem available.  To some extend the ICPC classification could be used. The International Classification of Primary Care.  The alphabetic code identify the anatomic system and the numeric represent more or less a functional point of view, i.e. an issue.