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[Gnumed-devel] Family Hx, Allergies etc containable as Health Issues and

From: James Busser
Subject: [Gnumed-devel] Family Hx, Allergies etc containable as Health Issues and feeding the caveats
Date: Wed, 16 Jan 2008 21:36:23 -0800

I am wondering to what extent it could be ideal to use GNUmed's health issue structure to manage what are considered "customary sections" of a patient's health history.

I could envision a health issue e.g. "Family Hx" which may be able to be created (if it did not already exist) as a debugged consequence of typing a keyword (e.g."fhx") and filling in the popup dialog.

A doctor could create one or multiple "episodes" nested under this item, one for each known or even suspected condition in the family. These items would most often remain inactive, but could be made newly active as the need arose. I could envision that when a patient presents with leg swelling that turns out to be a deep vein thrombosis (DVT aka "clot"), it may come up that the patient recalls something about their father having had a "clot".

Prior to the current clinical episode of leg swelling, it would have commonly gone unknown that his sister or father had had a "clot" and so this new episode "query clot in sister/father" could be created and nested under the Family Hx (in addition to the patient condition of DVT). The plan could include the need for the patient to obtain more information from his family and, in view of this being unresolved information, the episode could be made active. When the patient returns, he could reveal that his sister's clots had been a history of painful menstrual clots and that his father had had a heart infection passing a clot to his brain, permitting updating of this "episode" of family history and a redesignation as not active and not relevant. The family history would then disappear from the EMR tree and Progress note widget lists.

Conversely a determination of a family history of malignancy, especially premature or multiple malignancy, would cause such items to be marked "relevant" because to inform your patient's ongoing risk of personal cancer and help better decisions concerning screening and diagnosis. While always deserving to be relevant when reviewing this patient's overall problem list. the component items (episodes) might only be toggled "active" when useful to make them visible in the Progress notes widget, such as in preparation for a visit where the q3yearly colonoscopy is needing to be discussed and then made inactive when it yields a normal finding.

Even when a family condition is absent in a patient, that condition in the family member (think cancer, Huntington's, dementia) can be very important to your patient's health and/or their ability to keep to a care plan.

Social history could work in a similar fashion with respect to risk behaviours (smoking, ethanol, sex) and could include a subitem (episode) of relationship stress when applicable.

The beauty of what GNUmed already makes possible is that for any item in which *some other person* is discussed, for example in the family history, or in the social history where drug abuse or sexual or psychiatric issues (say, within the family or with partners) justifies the assessment or treatment of the patient, the SOAP editor makes it possible to preserve a record while segregating the directly or indirectly identifying information into threads that could be de- selected for export where a referral for consultation or a review of care did not require them.

Could allergies fit into such a model? Can a health issue, or one or more of that issue's episodes (relevant allergies, or a personality disorder or its periodically violent behaviour) programatically feed the caveats using a "caveats" indicator at the episode level?

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