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Re: [Gnumed-devel] encounter - translation

From: Rogerio Luz Coelho
Subject: Re: [Gnumed-devel] encounter - translation
Date: Sat, 7 Nov 2009 07:26:45 -0300

Ok so I´ll try to explain how I am using so far GNUmed and the way it stores my patient data:

*** I am not currently connected to a GNUmed DB so the terms in English could be messed up.

1st Visit) Patient gives name and DOB and tells why she came to me
- back pain.

-- ) Put "I have back pain" in the RFE field

-- ) take family history if any
  -- FUNDATIONAL HEALTH ISSUE = "Family History" with multiple --notes-- one for each     problem that is relevant (precocious CVD, genetical issues, Cancers, etc..)

-- ) take personal history
 -- ONE FUNDATIONAL HEALTH ISSUE PER PROBLEM = Hormonal Birth Control, Skin Problems, Osteo-Muscular problems, etc... AND a ISSUE called "Back Pain"

-- ) Start to colect the SOAP

-- ) Enlist all Measurements that are of note (I sometimes also put the REALLY important ones in the sOap field - so you can see them the next time you see the patient when you click on the open encounter view of the Note applet)

-- ) Define the Summary of the visit (here I think I start to get in some problems with the design)  as " First Visit, Back Pain , asked to do this and that and return in 2 weeks"


2nd Visit) Now 2 weeks pass and patient is better but not 100%

-- ) Click on "Back Pain" in the Note Plugin, new Note has "Back Pain" on the title.

-- ) RFE = " Better but not 100%"

-- ) SOAP

-- ) Summary = " Better but not 100%, start acupuncture and return weeklly for 1month"  ** ;) my free on-list merchandising ;) **

-- ) Save = GNUmed asks if I want to close the new or old (see ??? - I am thinking a little different of the design, because it seems obvious to me that if it was supposed to work the way I am doing things the client would not ask me nothing ;)

*** on the way out patient says "Oh doctor, I want to discuss also my Birth Control Method"

-- ) Click on "Hormonal Birth Control" and a new Note opens.

-- ) RFE = Birth Control Guidance

-- ) SOAP

-- ) Summary = Changed Birth Control method to Hormonal Pills with Drosperidone and only 4 days off = "Yaz"

-- ) Save


3rd Visit) one week later patient tells us she is better form back pain after last acupuncture session, seems 100%

-- ) RFE = Better, maybe 100%

-- ) Click on "Back Pain" - new note is created

-- ) SOAP

-- ) Summary = "Better seems 100%"

-- ) Click on "Hormonal Birth Control"

-- ) SOAP

-- ) Summary = "All is fine with 1 week use"


Any thoughts?

You see my method of using GNUmed is a Problem --> Visit paradigm.

Please feel free to enlighten what you think could change for easier use :)


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