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[Gnumed-devel] EMR journal soap row type / representation "ADM" & other


From: Jim Busser
Subject: [Gnumed-devel] EMR journal soap row type / representation "ADM" & other feedback
Date: Sun, 21 Jun 2009 15:14:34 -0700

I was looking at the rows in a journal and identified that the "Adm" is maybe not ideal. In English and with a major amount of hospital activity I am always thinking it means "Admit" and also the intended meaning "Administrative" is maybe not correct because these rows were in many cases user-entered by a clinician who was providing a clinical name for a foundational health issue or fpr a clinical episode.

Conveniently (at least, often), when an episode name had been provided (for a new episode), this record will be sequenced after the SOAP rows within this encounter, unless more get added before this encounter is closed.

Can we, in place of "ADM", show "=" in the S O A P column, as this still respects that the row was not a traditional soap row (but is rather a clinician-entered "meta" row) resulting from some clinical evaluation?

Likewise shown among EMR Journal rows as "ADM" are the Foundational Health Issues. These had also been user (clinician) entered (when they were not imported from a legacy EMR), and could also be argued to be derived if unverified entities. They could likewise be represented with "=" in the S O A P column?

Can the other "administrative" rows such as may arise from encounters created by lab results importers (or from record activation when browsing a record) be de-emphasized in the layout by designating them in the S O A P column with an"ellipsis" (three dots) instead of "ADM"?

Can we remove the word "Foundational" from "Foundational Health Issue" in the EMR Journal and simplify its appearance to
        "Health Issue: <issue name>"

I noticed in the journal an appearance of "Happened... None" for a sOap row "Allergy state: unknown, unasked (date time) and even while I was not (as a user) prompted to intereact with the allergy state I am wondering why it got documented? I suppose the system may be documenting that I did not ask it however I do not like that it is implying I should have, without it having offered to help me do what it seems to have decided I ought to be doing :-)






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