Re: [Gnumed-devel] need assessment from fellow clinicians

[Jim Busser]

I am trying to tie together how best to express a patient's clinical 
profile.

We have clin_health_issues
> long-ranging, underlying health issue such as "mild immunodeficiency", 
> "diabetes type 2"
these may start out as undifferentiated complaints, even left as 
"xxxDEFAULTxxx" upon creation by the desk staff, when there is no 
obvious existing health issue for them to attach patient-initiated 
Reason for Encounters (RFEs).

As each clin_health_issue is given care across a single or multiple 
episodes, the name (description) of clin_health_issue can be better 
tailored to take account of cumulative information but might diabetes 
mellitus become
DM, diet-ctrld -->
DM, on oral Rx -->
DM, on insulin

Presuming the patient over time develops complications, might we create 
*additional* issues
(alternative at bottom):

diab nephropathy (maybe even adding status information) e.g.
diab nephropathy - creat 150-180, prot .4g/d

However the clin_health_issue table provides no means to view these as 
related i.e. when sorting, the diving accident would be interposed 
between them, and if the second issue had instead been labeled 
"nephropathy, diabetic" many more items would sort interposed.

In the meantime, various clinical narrative entries will have permitted 
diagnoses to be coded in clin_diag. The sort order of whatever is the 
coding system might go part way toward a sort order that puts 
clinically-related items closer together in a list.

Alternative:
---------
If the health_issue is kept general (diabetes mellitus), it is still 
possible to accumulate a new coded diagnosis with each SOAP note. Since 
each of these clin_diag records could be related back to that one 
general health_issue it could be tidy to express (nest) the accumulated 
diagnoses underneath the general health issue. This is harder to do if 
the diagnoses are distributed across multiple health issues when each 
just reflects various dimensions of a chronic disease.

Probably it is not a great alternative, mainly because these dimensions 
can easily be active at the same time, and would benefit from the 
threading of assessments that could not otherwise be split out if all 
lumped under one general health issue.

So?
---
Within the multiple-issue approach above, it could still be useful to 
manage "relatedness" among the issues to ease better management. For 
example, angina (which might tempt a beta blocker) and asthma (which 
could be a reason not to use one) would be nice to position close 
together. So could "recurrent urinary tract infections" and "multiple 
drug allergies".

Maybe the most simple but fully flexible way is to just adjust the 
naming of the issues, together with leading numbers, to control the 
sort order?

Also, could the list of clin_health_issues could be filtered to remove 
from view any which did not have a clin_narr row related to a clin_diag 
row marked is_significant? Or is such a selection not very manageable 
across 3 tables?