Re: [Gnumed-devel] automatic episode namin

[Karsten Hilbert]

On Wed, Sep 07, 2005 at 07:01:35PM +1000, Richard wrote:

> Now consider this constation - patient comes in requests  a script for 
> paracetamol, the notes just say:
> 
> 20/10/2004     script paracetamol.
One could argue that these notes are incomplete since they
don't record WHY the patient was given a script for PCM. You
maintain that that's supposed to mean ...

> the RFE is implied is the 
> patient has said "can I have a script for paracetamol"

A judge may not agree. However, you are correct in saying
that there shouldn't be much of any hassle involved.

In my clinic(s) front desk staff would record "RFE: PCM
script request" so there is no need for me to do so.

I would simply record "Plan: script PCM for subfebrile child"

Of course, I agree the doctor shouldn't be bothered by
having to invent an episode name - because it's already
there, eg "RFE: PCM script request" !

And, of course, there would be a button saying "script
request" that would invoke a script which

a) let's me use a drug database for selecting the drug
b) thereby generates the RFE, Plan, script, encounter, episodes
c) prints the script
d) updates the medication record
e) saves the whole bunch to the backend

without anyone doing anything other than feeding a sheet to
the printer. Those are implementation details. They do not
dictate what the backend stores.

> > Should then the user be *prompted* for editing/ changing/
> > selecting the episode (name) the progress note actually
> > really belongs to ?
> 
> Definately not - one wants the least interuptions to consultation flow 
OK, good.

> Yes and no. You are making an assumption (which I think is not correct), that 
> everything the doctor types into the clinical notes is a problem or 
> associated with a problem, whearas in fact it might be a few lines of 
> clinical information as described with paracetamol above
Why, of course the patient got a medical problem: She is "in
need of paracetamol". If we know as much we should record it
(but should hardly have to *do* anything to get it recorded,
that's true).

> ===============================================
> IE after such verbosity, my opinion is don't enforce a progress note episode 
> name, but if you have to have a name stored in the back-end make it 
> anonymouse eg 'episode-drblogs-10/10/2004-1:54pm' and don't print it in the 
> EMRJournal when it is non-clinical.
> ===============================================
Yes and no. As far as I am concerned I think we will enforce
episode linkage in the database. However, I acknowledge that
anyone is free to write a frontend that uses dummy episode
names without even bothering the user about it as you
suggest.

It seems we can get some consensus here on how to make it behave.

Karsten
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