Recording problems and diagnoses in clinical care: developing guidance for healthcare professionals and system designers.
Anoop Dinesh ShahNicola J QuinnAfzal ChaudhryRalph SullivanJulian CostelloDermot O'RiordanJan HoogewerfMartin OrtonLorraine FoleyHelene FegerJohn G WilliamsPublished in: BMJ health & care informatics (2020)
Improving the recording of diagnoses and problems will require a major effort of which the new guidance is only a part. The guidance needs to be embedded in training, and clinical systems need to have improved, standardised functionality. Front-line clinicians, specialist societies, clinical informaticians and patients need to be engaged in developing information models for diagnoses to support care and research, accessible via user-friendly interfaces.