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Re: [Gnumed-devel] Progress Notes - still confusing

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] Progress Notes - still confusing
Date: Sat, 6 Sep 2008 00:20:42 +0200
User-agent: Mutt/1.5.18 (2008-05-17)

On Fri, Sep 05, 2008 at 05:09:43PM -0300, Rogerio Luz wrote:

> I see it this way:
> Patient Request: "I have a headache" - in patient´s own words
> Wich would be the same as RFE, but I think that if someone wants it he could
> change RFE to something more elaborated
> RFE = "I have a headache" - cronic / 3rd consultation for the same symptom
> (it is not that these things are diferent, it´s justa that
> it is easier to make headers cor consultation purposes this way, since the
> RFE can be seen right away).
> Subjective: Patient reports headahe with aura .... etc. (this is where the
> hole complaint and history will REALLY be stored)
> You are correct in saying that the "patient request" is part of the
> Subjective, but not all of the Subjective comes from his primarily
> complaint.

You are entirely correct and this is how GNUmed works ! :-)

The only problem is that currently the "Patient Request" is

a) (incorrectly) presented as an input field for *each* episode

b) (incorrectly) stored as just another Subjective

However, if you want to *make* GNUmed behave correctly you
can edit the encounter details and explicitely *set* the
RFE. It is a bit inconvenient and will be changed but that's
the only way for now.

> I see that a autoamatic way to make RFE is via de "Patient Request"

No, not yet.

> (and
> therefore the text of the "Patient Request" field should show this - as
> "This is the Reason for Encounter and it will
> be stored as the RFE of this encounter"). It is terminology, you use one
> time the RFE and other the "Patient Request" it IS confusing, expecially to
> the newcomer, or someone not familiar with
> these terms

It will be changed when the RFE / Patient Request thingy is reworked.

> IMO , The RFE should be shown imediatelly at the top of Subjective, the AOE
> can be where it is, but you see, when I start a Progress Note, the way it is
> systematically shown in editor fields makes me SUPPOSE that it will be shown
> that way on the Tree View, and that is NOT what is currently hapening.

> I don´t think there is a design problem in the way the pogram is eighther
> writen or expected, I think it is just a matter of terminology and display.

We are always happy to have input by clinicians but we are
short on manpower to quickly react to it.

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