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Re: [Gnumed-devel] 0.3.2 feedback: EMR tree also Past History item behav
From: |
Karsten Hilbert |
Subject: |
Re: [Gnumed-devel] 0.3.2 feedback: EMR tree also Past History item behaviours |
Date: |
Tue, 21 Oct 2008 20:12:11 +0200 |
User-agent: |
Mutt/1.5.18 (2008-05-17) |
On Sun, Oct 19, 2008 at 04:53:51PM -0700, Jim Busser wrote:
> Yes, there must have been an episode of illness. But there may -- or may
> not -- have been an episode of care around that illness.
To the point, as usual :-)
> I have been thinking further around retrospective documentation. Think of
> a patient who comes into the praxis with a discharge summary from a
> hospitalization during the 8 months that the patient lived and worked in
> Italy. I might choose make an episode "hospitalization, Florence IT"
> under the problem(s) which got care.
Under which I would file scans of the paper record w/o any
other notes for the time being.
> Each problem, where it would be
> useful, could cause me to input 2-3 lines of information so that I can
> better maintain a record of the patient's care (including care not
> delivered by me).
I agree that when I expect that patient to be a now-regular
it can be useful to pre-seed the record with a few select
health issues pulled from the Italy record.
> Can we think through how any difference between clin_when and care_when
> would be managed?
"old" health issue:
- clin_when: dob + age_noted from record content
- care_when: start/end of back-dated episodes taken from record
- modified_when: now
old episode:
- clin_when: defined by earliest/latest start/end of associated data/encounters
- care_when: same as clin_when
- modified_when: now
old encounter:
- clin_when: same as care_when
- care_when: defined by start/end
- modified_when: now
old soap/whatever data:
- clin_when: explicit where appropriate (vaccination, allergy, etc)
- care_when: defined by containing encounter
- modified_when: now
Might this belong into the wiki ?
Karsten
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