On Wed, Sep 07, 2005 at 07:01:35PM +1000, Richard wrote: > Now consider this constation - patient comes in requests a script for > paracetamol, the notes just say: > > 20/10/2004 script paracetamol. One could argue that these notes are incomplete since they don't record WHY the patient was given a script for PCM. You maintain that that's supposed to mean ...
> the RFE is implied is the > patient has said "can I have a script for paracetamol" A judge may not agree. However, you are correct in saying that there shouldn't be much of any hassle involved. In my clinic(s) front desk staff would record "RFE: PCM script request" so there is no need for me to do so. I would simply record "Plan: script PCM for subfebrile child" Of course, I agree the doctor shouldn't be bothered by having to invent an episode name - because it's already there, eg "RFE: PCM script request" ! And, of course, there would be a button saying "script request" that would invoke a script which a) let's me use a drug database for selecting the drug b) thereby generates the RFE, Plan, script, encounter, episodes c) prints the script d) updates the medication record e) saves the whole bunch to the backend without anyone doing anything other than feeding a sheet to the printer. Those are implementation details. They do not dictate what the backend stores. > > Should then the user be *prompted* for editing/ changing/ > > selecting the episode (name) the progress note actually > > really belongs to ? > > Definately not - one wants the least interuptions to consultation flow OK, good. > Yes and no. You are making an assumption (which I think is not correct), that > everything the doctor types into the clinical notes is a problem or > associated with a problem, whearas in fact it might be a few lines of > clinical information as described with paracetamol above Why, of course the patient got a medical problem: She is "in need of paracetamol". If we know as much we should record it (but should hardly have to *do* anything to get it recorded, that's true). > =============================================== > IE after such verbosity, my opinion is don't enforce a progress note episode > name, but if you have to have a name stored in the back-end make it > anonymouse eg 'episode-drblogs-10/10/2004-1:54pm' and don't print it in the > EMRJournal when it is non-clinical. > =============================================== Yes and no. As far as I am concerned I think we will enforce episode linkage in the database. However, I acknowledge that anyone is free to write a frontend that uses dummy episode names without even bothering the user about it as you suggest. It seems we can get some consensus here on how to make it behave. Karsten -- GPG key ID E4071346 @ wwwkeys.pgp.net E167 67FD A291 2BEA 73BD 4537 78B9 A9F9 E407 1346 _______________________________________________ Gnumed-devel mailing list [email protected] http://lists.gnu.org/mailman/listinfo/gnumed-devel
