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[Gnumed-devel] Info and to-do tracking schema

From: J Busser
Subject: [Gnumed-devel] Info and to-do tracking schema
Date: Sat, 25 Sep 2004 17:47:55 -0700

I would like to start working through possible schema needs for this.

Within a soaP note, the Plan will include

- things that may have just been done within the visit (reassurance, education, advice concerning non-drug and over the counter drug measures that could be tried, lifestyle changes and objectives, obtaining of any consent where applicable, and the ordering of any prescription medication and approval of any lab testing

- things that will need to be obtained or done, for example referrals to a specialist, the preparation of a referral letter or a report, booking for tests or procedures that will require appointments.

- the need for a return visit (which the doctor may leave to the front desk to do, or the patient may prefer to phone back and make the appointment later) as well as any future testing of a preventive or monitoring nature e.g. when the next INR or HbA1C or PAP smear will be due.

But there will also be information and requests for service that come into the office from outside, or that arise within the office *but* not inside an encounter e.g.

- the hospital has left a message indicating that patient X has been admitted to hospital
- pharmacy Y calls to indicate a patient has run out of medication
- a patient leaves a question asking if the doctor could call back
- a doctor's office or third party calls, indicating a need for records or for forms to be completed

Such pieces of information, whether or not they arose within an encounter or from outside an encounter, or originated within the office or outside the office, might be characterized as either:

1. information (a question or a message) which *may* warrant assessment or further action by either the creator (in case it is something they need to think on) or by some other person or role in the office/surgery or

2. an action that was taken, or which needs to be taken, by the creator or by some other person or role in the office/surgery

Both 1) and 2) would have nearly all the same fields and in fact a question requires action, and a message may require action, so these could all be housed in a "to_do" table (audited, of course).

How is this sounding, so far?

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