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Origin ID
QD32
Q-Code scope note
Q-Code conceptual content
CLINICAL SIGNIFICANCE a difference in effect size considered, on the basis of expert judgement, to be important in clinical or policy decisions, even though not statistically significant. (Woncadic)
DIAGNOSTIC SERVICE ; (Syn. investigative services) the assessment of any problem by history, physical examination, laboratory, imaging, or other examinations performed either inside or outside the office setting. (Woncadic)
CASE MANAGEMENT the process of medical care for a certain health problem in an individual patient from the first presenting symptom, REASON FOR ENCOUNTER, (RFE), through diagnosis to treatment. In case of a group of patients with a specific health problem accepted by medical professionals or health authorities it may be called a case management plan.(Woncadic)
CLINICAL STATUS (Syn. clinical health status) ; HEALTH STATUS of patients assessed in clinical settings by HEALTH CARE PROVIDERS using medical procedures and judgment. It can be described in terms of REASON FOR ENCOUNTER (REF), symptoms, signs, diagnoses, results of additional diagnostic procedures, severity of the health problem, CO-MORBIDITY, and FUNCTIONAL STATUS.(Woncadic)
DIAGNOSIS ; the determination of the nature of a disease, a medical name given by the physician for the health problem presented by a patient, family, or community. This may be limited to level of symptoms. The term covers both the process and its outcome and, in the case of a patient, represents the formal medical establishment of an episode. 1. Principal diagnosis: (Main diagnosis) - the most important problem, as determined by the health care provider. 2. Associated diagnosis: Another diagnosis made at the same time as the principal diagnosis. 3. Concurrent diagnosis: One which exists at the time of the encounter, but which is not dealt with at the encounter. (Woncadic)
DIAGNOSTIC CATEGORIES ; in general practice three diagnostic categories are used: 1. Symptom diagnoses using a symptom or complaint as the best medical label for the episode. 2. Nosological diagnoses (Syn. syndrome) using a symptom complex based on consensus among physicians, but which lacks a proven pathological or pathophysiological basis or aetiology. 3. Pathological/pathophysiological diagnoses having a proven pathological/pathophysiological substrate and/or proven aetiology.(Woncadic)
DIAGNOSTIC CLUSTERING ; placing diagnostic categories in groups of discrete clinical conditions, which are clinically related and suited for comparative analysis. By reducing the confounding effect of coding practice by individual physicians clustering increases the comparability of data from different populations. (Woncadic)
DIAGNOSTIC CRITERIA the symptoms, complaints, objective signs, and/or test results which are essential for labelling a health problem i.e. making a diagnosis. (Woncadic) DSM-IV (abbr. for Diagnostic and Statistical Manual of Mental Disorders IV) a coding system for accurate classification of psychiatric disorders for both in-patient and out-patient populations. (Woncadic)
DIAGNOSTIC PROCEDURE ; procedure used to arrive at a diagnosis. Can include the taking of the history and the performance of a physical examination, but usually refers to additional diagnostic procedures such as laboratory or radiologic procedures.(Woncadic)
DIAGNOSTIC TEST ; A procedure to provide information about a person's condition that helps health care providers to make a diagnosis. Diagnostic tests provide information about whether a person does or does not have a particular disease (AHRQ)
Disease Management ; A broad approach to appropriate coordination of the entire disease treatment process that often involves shifting away from more expensive inpatient and acute care to areas such as preventive medicine, patient counseling and education, and outpatient care. This concept includes implications of appropriate versus inappropriate therapy on the overall cost and clinical outcome of a particular disease. (MeSH)
HEALTH PROBLEM ; any concern in relation to the health of a patient as determined by the patient and/or the HEALTH CARE PROVIDER. Problems should be recorded at the highest level of specificity determined at the time of an encounter. GPs/FPs see patients with HEALTH PROBLEMS which are not diseases and may not develop into disease. 1. New problem: The first presentation of a problem, including the first presentation of a recurrence of a previously resolved problem but excluding the presentation of a problem first assessed by another provider. 2. Continuing problem: A previously assessed problem which requires ongoing care. It includes follow-up for a problem or an initial presentation of a problem previously assessed by another provider.(Woncadic)
ILLNESS : the subjective state of the person who is aware of having a health problem and not feeling well. Includes the feelings, thoughts, concerns and effect on life that any episode of sickness induces. (Woncadic)
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Citation
Mohanan S, Tapp H, McWilliams A, Dulin M. Obesity and asthma: pathophysiology and implications for diagnosis and management in primary care. Experimental biology and medicine (Maywood, N.J.). 2014; 239(11): 1531-40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24719380
Smellie WS, Shaw N, Bowley R, Stewart MF, Kelly AM, Twomey PJ, Chadwick PR, Houghton JB, Ng JP, McCulloch AJ. Best practice in primary care pathology: review 10. Journal of clinical pathology. 2007; 60(11): 1195-204. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17496187
Stone L. On botany and gardening - diagnosis and uncertainty in the GP consultation. Australian family physician. 2012; 41(10): 795-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23210103
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