Re: [Gnumed-devel] vocabulary question - doctors, please speak up

[Karsten Hilbert]

On Wed, Nov 29, 2006 at 09:07:57AM +1100, Richard wrote:

> When I'm using an electronic record and the patient comes to see me I'd add 
> notes under the headings of say, Hypertension, Depression. I would select the 
> condition from their past history list, and say by right mouse clicking on it 
> I'd select an option such as 'new contact' or 'add progress notes for 
> depression'.
Yep, that's exactly how it works in GNUmed.

> IE a paper/html representation of a typical consult may look like:
> ----------------------------------------------------------------------
> Hypertension
> 
> BP = 120/70 script tenormin.
> -------------------------------------------------------------------------
> Depression
> 
> Seems stable, things settling at home, has decreased his ssri to 10mg and 
> wants to get off it over next couple of months. Discussed in detail.
> ------------------------------------------------------------------------------------
> Abdominal Pain (NOS)
> 
> Vague upper abdominal pains, ?colicky, ?related to food, but sometimes
> worse with movement, gets a little reflux, possibly loose bowels.
> O/E: NAD, 
> Dx ? see if dosn't settle for further Ix
> --------------------------------------------------------------------------

Yes. I am working on this sort of notes formatting for the
next incarnation of the progress notes editor.

> Now there could be some notes you don't really need to put anywhere:
> 
> eg. - next visit - check his BP, and ask about his mums breast cancer.
For which you used the concept of scratch pad. Which I agree
with but haven't implemented yet.

> Next when the patient comes in, this entire sheet is in front of you on the 
> just all the consults for hypertension, you could click over that and just 
> display that.
Yes. This filtering is done by GNUmed already.

> We don't tend to have health issues.
You do. You just don't care to differentiate "health issues"
(Grunderkrankungen) and episodes. You cannot avoid them.
They are medical facts of life. But you can chose to ignore
them.

> We tend to group other non-medical things also on the problem list.
No problem. In fact, one of the practices that uses GNUmed
does that to make up for the current lack of input widgets
for, say, family history etc.

Unfortunately, you haven't given any advice on the question
I asked, namely, how to better name "health issue".

Karsten
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