On Fri, May 06, 2011 at 08:31:18AM -0300, Rogerio Luz wrote:
> > PS yes, it is possible to put the word "hypertension: into the RFE.
> > However, the unmanaged problem of hypertension is less apt to get missed if
> > it would be in the episode name than if it is just in the RFE, and RFE does
> > not accept codes if the user wished to add the code.
> >
> I have thought a long time about this ... and I am willing to explain my
> predicament:
>
> Say patient was seen in 2011 and the doctor said he had High Blood Pressure
> (HBP) and gave him low dose Hydroclorthiazide (hope the spelling is right).
> This made his BP stable. In 2015 this patient returns, has a stable BP, and
> someway forgets that his HCT is for BP and tells the new doctor he never
> knew he had HBP.
>
> Doctor removes HBP form the code and then all sorts of bad things can happen
I see what you are getting at.
> Here in Brasil the ICD 10 code is necessary for inumerous interactions with
> legal and funding issues,
Same here. No ICD 10, no reimbursement.
> the ability to change ICD (or better yet the
> ability to DELETE a ICD) is a deal breaker in the design of a EMR. It is
> expected that if a ICD was entered wrongly, there be a explicit way (even if
> a note on the SOAP entry that made this mistake) to correct this wrong
> doing, but there must NOT be a way to modify-delete this ICD.
We can add a hook "post-code-removal" or "pre-code-removal"
which would let the user implement the local policy that
removed codes will be written to the clinical narrative
journal as a row, saying that such-and-such a code was
removed for this-or-that episode