Using Condition for self (patient) reported conditions

Does anyone have an example of how a self-reported condition should be captured as a Condition resource, especially where they may be entering this information via a self-service interface? In discussions around this, the concern that comes up is that a patient isn’t going to know the correct Snomed-CT code or ICD-10 code to use.

Has anyone done this? If so, is the typical approach to not use any coding system, capture the raw text, make sure the recorder and the asserter are set to the patient themselves, and set a verificationStatus of unconfirmed?

The differentiator would be that the Condition.recorder would be the patient (or perhaps a RelatedPerson). It would be more common for patients to record symptoms (as Observations) rather than diagnoses. However, if a system chooses to allow patients to record Conditions, it’s up to the system whether to put any constraints on assertions of verification. The reality is that some patients will be more accurate than some clinicians, others significantly less so. The source of the information always matters…

Lloyd, in this case of using Observation as a self reported condition of a patient, what Observation.category you would use?

In the scenario where the patient report a complaint that has lead to the encounter, would it still be represented in the Observation resource?

Values in Observation.category are likely to be domain specific, and even implementation specific. Use values of category are useful in your context. Who are you exchanging information with? What do they expect? Maybe do not use any.

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Observation is suitable in this type of case.

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