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Re: [Gnumed-devel] question reg prog note when entering past medical hi

From: J Busser
Subject: Re: [Gnumed-devel] question reg prog note when entering past medical history item
Date: Fri, 22 Apr 2005 00:28:07 -0700

At 9:41 PM +0200 4/21/05, Karsten Hilbert wrote:

Consider a patient with Crohn's Disease which I've been seeing
for two months to get the recent flare under control. While
entering notes during today's encounter the patient suddenly
feels like informing me of his last-year bout of heavy NSAID
use due to now-chronic polyarthritis. I decide that the CPA is
a health issue/past history item I want to store in GNUmed.
Hence I type "phx" and up pops the edit area for past medical
history. I enter "chronic Polyarthritis", "age 47", "11/2004
heavy use of Ibuprofen due to acute bout", respectively, for
condition, age_noted, progress_note. This will result in a new
health issue "chronic Polyarthritis" with a proxy episode "past
medical history" and an attached S(oap) row "11/2004 heavy use
of Ibuprofen due to acute bout". However, in the clin_narrative
row created for the Crohn's Disease problem that I am currently
working under we would *also* want to add a short blurb (eg
embed a string) like "relates history of 'chronic
polyarthritis' known since 'age 47'".

Now, the question is: would we want to also embed the
(potentially quite long) progress note or leave that for
storage under the new health issue only ? I tend to think the
latter is better.

In the case of a patient reporting a "past history' issue, you might enter quite a bit of detail into that "new" (retrospective) health issue. Are you asking whether to embed (i.e. copy) the entirety of *that* into the Crohn's Disease row?

I agree with your idea to NOT do that. It would be analogous, would it not, to a patient having 2 issues dealt with at the same visit, whose content you put into component encountlets? You would not copy the content of one progress note into the other!

A workflow question. As part of creating a phx item, would a selection of soap text of interest "11/2004 heavy use of Ibuprofen for acute bout of chronic polyarthritis" be lost (unselected) as you type "phx" or would the selection be kept by virtue of some special key you would press before typing "phx" to invoke an edit area?

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