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Re: [Gnumed-devel] Example usage of GNUmed - to be inserted in the wiki.

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] Example usage of GNUmed - to be inserted in the wiki.
Date: Mon, 18 Aug 2008 00:07:06 +0200
User-agent: Mutt/1.5.18 (2008-05-17)

On Sun, Aug 17, 2008 at 06:34:31PM -0300, Rogerio Luz wrote:

> So far I have the following:

All in all a very good and valid example !

A few notes below:

> *Clinician* opens a "Health Issue" with Hypertension as the name, brings up
> a SOAP via the "Progress Notes" tab in the bottom of the GNUmed sreen, and
> takes past and family history, when he discovers that patient has Aortic
> Aneurism,
> *Clinician* opens a new "Health Issue" with Aortic Aneurism as the name,
> where he opens a SOAP via "Progress Notes" and includes the time of onset
> and current treatment regimens - *_SAVES_* and goes back to Hypertension

Both progress notes for Aortic Aneurism and Hypertension can
be worked on concurrently. There is no need to save the one
to work on the other. Just thought I'd mention.

> Patient leaves, Clinician opens new patient, when new patient exists, Mr R.
> (who was waiting asks if he can talk just one more minute..

> *Clinician* opens the patient again, *_system_* asks if it should generate a
> NEW Encounter or continue the last one (configuration of the time it takes
> since last editing patient and new edit done via - ******* I DONT´T KNOW HOW
> TO DO THIS ******** )

Menu "GNUmed" -> "Options" -> "EMR" -> "Encounter"
 minimum duration
 maximum duration

> *Clinician *opens a new "Progress Notes" (clinician does not yet know under
> wich "Health Issue" he wants the new episode to be stored under) and starts
> working on the hystory and recurrency of the chest pain etc..., he
> orders patient to emergency department of local hospital,  when he 
> *_SAVES_*the
> *_system_* asks under wich Health Issue he wants to save, he leaves it in
> the UNKNOWN - because he wants to define if chest pain is due
> to Hypertension, Aortic Aneurism, or any other thing.

That is correct. The chest pain will be an unassociated
episode. The system will ask for an *episode* name, not the
health issue name when saving the new episode. So, the
clinician will set the episode to "chest pain". But that
episode will NOT be associated with any of the Hypertension,
Aortic Aneurism or Reflux health issue yet.

Later on, when the hospital properly diagnosed the root
cause of the chest pain episode the clinician can link that
episode to the proper (perhaps new, say, barret esophagitis)
health issue.

Makes sense ? :-)

The proper place for your description would be somewhere
down in the "clinical use cases" part of the wiki.

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