Findings (medicine)
Findings (Latin status praesens ) designates medically relevant, physical or psychological phenomena, circumstances, changes and conditions of a patient , which are recorded by specialist staff ( doctors , other medical staff) as an examination result. This is done using a wide variety of research methods and tools, and the results are documented in a wide variety of ways (text, graphics, images, sound, etc.).
Findings can have extremely different contents, for example an efflorescence , the sound when tapping the body surface, the level of the blood sugar level or a certain behavior of the patient. An abnormality shown by an imaging method , the result of a DNA analysis and many other things can also represent a finding.
Findings report and types
The diagnosis usually follows a systematic examination. A summary of all individual findings can be found in a findings report, whereby the results always relate to the time of the examination. The status praesens describes the current condition of the patient.
Overall findings
An overall finding represents the sum of all individual findings and is usually part of an epicrisis . Since a finding relates to established, intersubjective phenomena, it is differentiated from the patient's anamnestic , subjective information.
Pathological finding
The expression " pathological finding" denotes a pathologically altered finding. If a certain examination does not produce any pathological findings, but rather normal findings, documentation is usually carried out using the abbreviation “o. B. “( no findings ) or" opB "( no pathological findings ).
Histological findings
The histological findings report on the analysis of a microscopic tissue sample or a surgical specimen. The report also includes the analysis methods used, special tissue properties and possible interpretations and their alternatives.
Psychopathological findings
Documentation and patient record
The creation and documentation of a finding is one of the essential medical professional duties, especially with regard to the proof of performance in billing issues, as well as in the case of legal disputes. The findings can be recorded in the appropriate documentation sheets. The main complaint and accompanying complaints lead to suspected diagnoses, which in turn lead to specific findings and finally to work diagnosis and therapy. In addition, structured documentation of findings serves for communication and cooperation between all involved doctors, clinics and institutions, which is increasingly supported by the development of telemedicine . The more structured and standardized findings are documented, the better they can be compared with one another and the course of the disease assessed. This is particularly evident in specialist areas in which numerical findings are often collected, such as in ophthalmology ( visual acuity , intraocular pressure , refraction and glasses values , stereopsis , squint angles, etc.).
With the patient rights law , the doctor or dentist was obliged by § 630f BGB - as previously regulated in the professional regulations and in the federal shell contracts - to keep a patient file and to document all relevant facts, including the findings, in detail. Subsequent changes in both the paper and the electronic patient file must show the specific content and the exact time of the change.
Demarcation
A doctor can derive a diagnosis from the medical history ( anamnesis ) and a constellation of findings obtained , whereby he ascribes a disease entity to the patient . Findings that cannot be explained by a diagnosed disease are referred to as secondary findings , which in turn can represent symptoms of other diseases that require further diagnostic clarification.
Survey results that have not been explicitly searched for are called incidental findings .
Although this is often not clearly differentiated in everyday language use, the findings and symptoms can be distinguished from one another. While the term finding emphasizes the empirical character (the collection of information) of recorded characteristics, symptom emphasizes the appearance of a characteristic itself, as an indication of a disease.
swell
- Jürgen Dahmer: Anamnesis and findings . Thieme Verlag, 2006. ISBN 3-13-455810-6 .
- Hans von Kress (ed.): Müller - Seifert . Pocket book of medical-clinical diagnostics. 69th edition. Verlag von JF Bergmann, Munich 1966, pp. 1-4 ( medical history ), especially pp. 2-4: findings (status praesens) .
Individual evidence
- ↑ Cancer Information Service, German Cancer Research Center: Doctor's Letters: Understanding Findings. Retrieved June 24, 2017 .
- ↑ Albertinen | Lexicon of Medicine - Histological Findings . Website Albertinen-Diakoniewerk eV Retrieved January 18, 2015.
- ↑ Example of a findings sheet , from Dahmer, anamnesis and findings
- ↑ SpringerMedizin.at Sending Findings Instead of Patients: Medicine at a Distance , June 2007 ( Memento from January 4, 2014 in the Internet Archive )
