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Re: [Gnumed-devel] automatic episode namin
From: |
Richard Terry |
Subject: |
Re: [Gnumed-devel] automatic episode namin |
Date: |
Wed, 7 Sep 2005 19:01:35 +1000 |
User-agent: |
KMail/1.8.2 |
On Wed, 7 Sep 2005 05:55 am, Karsten Hilbert wrote:
> Richard, all,
>
> assume you entered a progress note. You did not select
> beforehand which episode it belongs to.
I have a feeling my reply will be confusing because of my confusion about
episodes vs problems vs consutations, however:
Just a question here, maybe I'm finally 'getting it', is your 'episode' the
equivalent of what I'd call a consultation? ie the period of time the patient
is sitting in front of me in my room? (or on the phone, or at home etc). This
seems to be the case from looking at your EMR Journal dump, but maybe not. I
have a horrible feeling your concept of episode is something that spans
several consultations ie captain kirks lacerated wound, starts an episode,
and all subsequent parts of consulations related to that wound are episodes?
is that closer? I guess in AU we would simply call that a diagnosis or
problem.
>
> Upon saving the system will try to determine a suitable name
> for the episode. First it will enforce that the progress
> note contains at least RFE and Plan. It then uses either
> Assessment or RFE (in that order) to chose a name for the
> episode.
Mmmmm, problematic. Malcolm ireland (remember GP/Acadenmic/IT degree/presenter
at many many international medical record conferences over the years) and I
debated this many moons ago and some of this is reflected below.
I disagree about the enforcement stuff, and I don't beleive every time the
patient sits before me one needs to 'name' the encounter. To me linking the
encounter to a problem (eg Hypertension) is a different issue from needing
some sort of summary tag for the consultation eg 'Flu' or "Investigation of
chest pain'. I do beleive the option should be there for the doctor to add a
summary tag (I do this all the time in my notes - in the right most column to
allow me a visual vertical flow chart for when I have to go back through the
notes) - as per the png file enclosed of my 'mock up' wx2.6 medical records.
Think about this as two extremes
Why in the first place have we chosen to have a multi-lined progress note?
This has more to do with organisation of information than anything else. For
example context sensitive pop up phrase wheels can be implemented according
to whilch line the user is on.
Remember my postings some time ago when I tried various combinations of
headings, when I entered progress notes using a widgit during real
consulations and posted the png's to the list - ie headings such as SOAP, or
Patient history, Dr History, clinical Findings, Assessment, plan, or Patient
Request, etc etc, and I commented that I found NONE (sorry Sebastian for
shouting) of them worked terribly well to encompass all types of
consultations, not in the png I've used symptoms, examination, assessment,
treatment/plan (which sits probably best with me of all the wordings - ie
the old SOAP in another guise!).
Now at the other extreme consider that many medical records programs have as
their data input area - a single large textbox, where the user combines all
the information as they so desire.
Now think about what you put down on a page (this is how I do anyway),
20/10/2004 Complaining of headaches, myalgia
No skin rash, no fever bla bla
O/E T=38 BP=134/70, no meningism, red throat
chest clear, no rashes
Dx viral influenze
Rx symptomatic script panadeine forte,
advised review if deteriorates
pm visit:
Sudden deterioration, haemorrhagic rash
obtunded, BP 60/40
Dx Meningococcal Septicaemia
Rx ivi penicillin, urgent transfer to hospital
Now niether of these visits are 'tagged' but it is self evident what has
happened (and what will happen - ie I will be sued bit time for
misdiagnosis!)
Now consider this constation - patient comes in requests a script for
paracetamol, the notes just say:
20/10/2004 script paracetamol.
ie nothing else is needed. Not linked to anything, the RFE is implied is the
patient has said "can I have a script for paracetamol", you should not have
to write that in the notes. The action is on the plan line only "ie script
paracetamol).
I guess what I'm saying is that whearas you should obviously not save a blank
consultation, the information for the consultation may be written on one or
more of the input lines and is really the responsibility of the user.
>
> Now the question:
>
> Should then the user be *prompted* for editing/ changing/
> selecting the episode (name) the progress note actually
> really belongs to ?
Definately not - one wants the least interuptions to consultation flow
possible. Our major medical program uses such prompting. Users spend all day
having to type into stupid boxes or click on ok/cancel buttons to get
anything done - adds thousands of extra clicks/mouse movements a day.
>
> The alternative would be:
>
> Assume that an "as-yet unassociated progress note" is just
> that - a *new* problem - or else the problem would have been
> pre-selected from the problem list.
Yes and no. You are making an assumption (which I think is not correct), that
everything the doctor types into the clinical notes is a problem or
associated with a problem, whearas in fact it might be a few lines of
clinical information as described with paracetamol above, not related to
anything at all and may or may not ever be, ie it is a clinical note which
needs no tag at all.
> Hence guess a "good"
> episode name and store the progress note under that name as
> a new episode. The user can always come in later and
> associate the note with another episode (which, of course,
> won't happen in a busy practice).
Yes, the user should be able to associate that particular progress note with a
problem, and I expect it would happen quite commonly. This is what I've
previously discussed as 'linking' a SOAP encounter to a particular problem.
No, don't guess a name at all.
===============================================
IE after such verbosity, my opinion is don't enforce a progress note episode
name, but if you have to have a name stored in the back-end make it
anonymouse eg 'episode-drblogs-10/10/2004-1:54pm' and don't print it in the
EMRJournal when it is non-clinical.
===============================================
Now as a final comment, just to make you think I'm disagreeing with myself
completely, I do believe the as the patients case-notes are being saved, a
modal (yes modal) dialog box should pop up and ask the doctor for a one line
(or suggested by intelligent interpretation by the program) summary, to be
later displayed as per the png file below. This of course could be blank.
Regards
Richard
>
> Karsten
progressnotes_wxdemo.png
Description: PNG image