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Re: [Gnumed-devel] clinicians: coding use case survey - please respond !


From: Karsten Hilbert
Subject: Re: [Gnumed-devel] clinicians: coding use case survey - please respond !
Date: Mon, 9 May 2011 12:03:29 +0200
User-agent: Mutt/1.5.21 (2010-09-15)

On Fri, May 06, 2011 at 08:31:18AM -0300, Rogerio Luz wrote:

> > PS yes, it is possible to put the word "hypertension: into the RFE.
> > However, the unmanaged problem of hypertension is less apt to get missed if
> > it would be in the episode name than if it is just in the RFE, and RFE does
> > not accept codes if the user wished to add the code.
> >
> I have thought a long time about this ... and I am willing to explain my
> predicament:
> 
> Say patient was seen in 2011 and the doctor said he had High Blood Pressure
> (HBP) and gave him low dose Hydroclorthiazide (hope the spelling is right).
> This made his BP stable. In 2015 this patient returns, has a stable BP, and
> someway forgets that his HCT is for BP and tells the new doctor he never
> knew he had HBP.
> 
> Doctor removes HBP form the code and then all sorts of bad things can happen

I see what you are getting at.

> Here in Brasil the ICD 10 code is necessary for inumerous interactions with
> legal and funding issues,

Same here. No ICD 10, no reimbursement.

> the ability to change ICD (or better yet the
> ability to DELETE a ICD) is a deal breaker in the design of a EMR. It is
> expected that if a ICD was entered wrongly, there be a explicit way (even if
> a note on the SOAP entry that made this mistake) to correct this wrong
> doing, but there must NOT be a way to modify-delete this ICD.

We can add a hook "post-code-removal" or "pre-code-removal"
which would let the user implement the local policy that
removed codes will be written to the clinical narrative
journal as a row, saying that such-and-such a code was
removed for this-or-that episode

> What I need you guys to understand is that the EMR journal is the way LEGALY
> we see EMR in Brasil, so I need it to show somewhere in the journal a ICD
> field.

That's good to know. Please list the places where you need
it to show.

Karsten
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