Thomas, apologies for I at times respond a bit too rashly :-)
I was not trying to advocate to just base decisions on what the patient tells me. I was just struck by the example: patient with elevated temperature, coughing and slight difficulty breathing (generally feeling unwell) just having arrived from a known SARS area. My response was simply based on those facts and the only sane (clinical) response is to get the patient to the next infectious diseases ward relatively quickly for further assessment. This is, of course, coloured by my working in a clinic, not a hospital department. However, it would certainly be very wonderful to be able to access OpenEHR()ed records from the backwaters of China but I wonder if I'll live to see that happen (I'm 28). So, yes, electronically available pre-recorded information is very helpful and OpenEHR is immensely useful at any of those parts of dealing with the above patient. > obvious bump on the head (swollen). The Emergency Room nurse > retrieved my name and address and then asked if I was in pain. Being > Irish is a detriment at times, but I managed to respond that I was indeed > in a lot of pain, was unable to stand, could not drive a car, and a prior > neck injury was causing considerable distress, all of which was already > on the record (same hospital and ambulance technician record). Your current assessment of a situation is just as valuable as what is recorded somewhere. I routinely do ask patients for about the same information (or more specifically their current assessment of said information) that they have provided previously. It does help to establish a clinical path beforehand such as "We will attend to alleviating your current discomfort right away but I must re-assess some information because some of the further treatment may alter your perception of it." I have generally found patients very responsive to that explanation. It takes about 2 seconds. Karsten -- GPG key ID E4071346 @ wwwkeys.pgp.net E167 67FD A291 2BEA 73BD 4537 78B9 A9F9 E407 1346 - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
