>-----Original Message----- >From: Cedric Meyerowitz [mailto:[EMAIL PROTECTED] >Sent: Wednesday, 6 December 2006 9:04 AM >To: 'General Practice Computing Group Talk' >Subject: RE: [GPCG_TALK] Re: BP or not BP? > >Our working party for nursing homes in our division would like all nursing >homes to have computerised Dr & nurses records. Using MD or BP can make >this happen. Nurses log on as nurses & do their notes & Dr logs on as Dr & >does his / her notes. Every-one must be able to read all entries whether >made by a Dr or nurse, physio. Etc. What clinical ins & outs & obs do >nursing homes do that can't be catered for? If you let me know, >we can work >on this.
I was thinking of the various assessments such as continence and pain but I suppose these could be developed as templates. I haven't eye-balled any of the aged care pro-formas for these types assessments so don't know if they require any clinical data not recorded in conventional GP EHR fields but was wondering about: - nutritional intake - continence flow - fluid balance - pain management charts - restraint management charts I may not be asking the question the right way, but my query is, do the data from these types of charts need to be input in a manner that allows it to be pulled out later in quantifiable format, rather than just freely typed progress notes? For example, line graphs or tables or any other reason? I draw a parallel to inputting regular data into something like MD Blood Glucose Monitor, Blood Pressures, heights, weights etc; or to be able to construct a report or summary in a template populated by fields e.g. Mrs Smith had restraints applied on [Table of Dates and type of restraint and reason pops in here] And, from what I recall of geriatric rehab in America, Physios and OTs had to record measures such as Range of Motion, strenghtening based on a scale, type and repetition number of various exercises, use of assistive devices, ADLs addressed with number of prompts/assists and on and on. They had to be able to develop and address a problem list and goals/pt outcomes. And I believe the trend there these days is to capture data back out of physio software for review and analysis (IM was with pen and paper on triplicate carbon copies when I was involved in that arena). This is just what I could think of off the top of my head and I am probably being totally anal about this but wondering exactly how it would all be fit into GP software. Cheers, Jan _______________________________________________ Gpcg_talk mailing list [email protected] http://ozdocit.org/cgi-bin/mailman/listinfo/gpcg_talk
