Textual definition of "Clinical History Taking" potentially underinclusive

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> "Clinical history taking": "Interview" is part of the textual definition,
> but not defined in OGMS. Are we sure that all clinical history taking is
> going on in interviews?

Comment by Albert Goldfain:
"Good point.  Maybe something more general is in order to accommodate
surveys and other forms of interaction"

Original issue reported on code.google.com by MBrochhausen@gmail.com on 9 Dec 2010 at 7:32

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Original comment by albertgo...@gmail.com on 9 Dec 2010 at 7:45

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Two issues:

1.  The definition of 'clinical history taking' is still "An interview in which 
a clinician elicits a clinical history from a patient or from a third party who 
is reporting on behalf of the patient."

I think we can account for other means of obtaining information about a 
patient's clinical history by simply changing 'interview' to 'process'.  If it 
needs to be more specific, the definition can include examples of (or an 
exhaustive list of) processes that are used to elicit a clinical history.  
These could include interviews, surveys, filling out standard medical forms, 
and perhaps other means of obtaining the pertinent information about the 
patient.

2.  I doubt that it has to always be a clinician who is doing the elicitation 
of this information.  Can't a non-clinician elicit this information for the 
purposes of generating a clinical history?  In some cases, it might be an 
employee of a clinician doing an interview.  In other cases, there might be a 
mass mailed (or online) survey (perhaps for the purpose of keeping track of a 
patient's disease progression at minimal cost) that might even be conducted by 
a third-party organization.  There are probably other good examples of 
non-clinicians performing similar tasks as well.

The current definition can be defended by stipulating that it is only a 
clinical history taking if it is performed by a clinician.  Otherwise, it is 
something else.  This seems too restrictive, but may be refined to include 
instances in which clinicians are involved in the clinical history taking 
process only insofar as they requested that the information be collected.

A possible revised definition of 'clinical history' is: "A process in which a 
clinician elicits, or requests a third party to elicit on behalf of the 
clinician, a clinical history from a patient or from a third party who is 
reporting on behalf of the patient."

Original comment by Alexande...@gmail.com on 13 Jun 2012 at 5:25