On Tue, Sep 13, 2005 at 11:58:00AM -0700, Jim Busser wrote: > We could have > - diabetes mellitus (control) > S - Having trouble adhering to diet. Checking ~ 2x daily, staggered > times, 9-13 mmol/L > O - Last A1C 0.09% ( is it under O we would comment on test results, > or under A?) > A - Agrees to incr meds while continuing effort at wt loss > P - Incr metformin 500->850mg bid > (using whatever trigger text would activate the medication list) > > - diabetes mellitus (foot care) > S - Noted slight drainage on socks past 3 days. No > pain/red/fever/trauma but new shoes 7d ago. > O - (Details of exam) > A - Whatever > P - Whatever > > likewise for dyslipidemia and hypertension > > Richard may prefer to enter all this in a *single* SOAP note (maybe > I'm wrong). But under what Karsten has been proposing, the "parts" > (dm control, foot care, lipids & hypertension) would each be > encountlets (encounter-lets) within one encounter. Precisely.
> So if the RFE originated from a patient saying "foot problem and > refill BP meds" is this a single row RFE that gets attached > unalterably to whichever issue the front desk or the doctor chooses? Not unalterably but, hey, I think you have a point here: Should we not make RFE attach to the *encounter* instead of it being a clin_narrative row (which would need to be attached to one episode only) ? Surely the patient isn't expected to deal with episodes and present suitable RFEs. Still the RFE can be auto-copied for edition into Soap for each episode that's appended to during the encounter. > Is there a requirement that each encountlet have an RFE, or can we > have a single RFE for the encounter? Likely the latter - what do other clinicians think ? Elizabeth ? > In our display of what occurred in that encounter, if in the EMR tree > we clicked, inside an issue/episode, onto a single encounterlet, we > would presumably see only its parts (together perhaps with a shared > RFE if it's possible). Yes, it is possible. > However it is important that we be able to "see' the entirety of what > occurred in a visit. So we would need a means of being able to select > an encounter (meaning to include/display all encounterlets from that > encounter). Sure. That view is still missing from 0.1. I hope to have it in 0.2. > RFE > S1 > O1 > A1 > P1 > AOE1 Actually, IMHO: RFE S1 O1 A1 P1 AOE where AOE == clin_encounter.description == clin_encounter.aoe == consultation summary == edit(soAp1 + soAp2 + ... + soApX) > If not, would the user have an option of using a single AOE to tie > together the parts into a synthesis e.g. new shoes / cellulitis / > hyperglycemia / high BP (role of NSAIDs?) Yes, that would be Richard's consultation summary. We already support it now. > Can the AOE be attached to the encounter without having to be > attached to a specific health issue? Yes. > Encounter date/time > AOE xcvxcv nbncxb bxnbcnx > expansion triangle > > under the expansion we would have the encounterlets that made up the > encounter, and each encounterlet would be denoted by its issue name & > assessment info (or AOE if this had been input down to the > encounterlet level?) Yes, that's the second EMR tree view I hope to have in 0.2. 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
