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Re: [Gnumed-devel] terminology question
From: |
Jim Busser |
Subject: |
Re: [Gnumed-devel] terminology question |
Date: |
Thu, 02 Apr 2009 08:40:42 -0700 |
I confess I am not yet trying the software enough but hope to catch
up soon. Even so
On 2-Apr-09, at 5:55 AM, Sebastian Hilbert wrote:
Patient suffers from AV-Block III° and receives a dual chamber
pacemaker.
Health issue/Grunderkrankung would be AV-Block III° I assume.
Pacemaker
implant procedure would be what in that context ?
I see no way to avoid granting that the pacemaker is its own health
issue. The patient had a procedure done, which was an insertion, and
can have been a progress note attached under AV-blockIII. However at
the same time that the progress note is made, I see no escape to
adding a new health
issue
status post-pacemaker insertion
(I would abbreviate s/p) with the details of the pacemaker. This
issue would remain active and relevant. If the pacemaker was later
removed it would be set inactive but perhaps always relevant because
it could be important to not miss this in a later inspection of all
things irrelevant like minor self-limited conditions like viral
infections
If patient comes in for a pacemaker checkup and I want to write a
soap note I
would select av-block as health issue. What am I supposed to put in
to reflect
that the reason for encounter was a pacemaker checkup (not a
problem in that
case).
You would instead put it under
status post-pacemaker insertion
What if the patient suffers from device associated infection. Is
this a
seperate health issue or is the issue AV-Block III° and the active
problem the
device associated infection ?
The infection becomes a new problem until it is resolved, after which
it becomes inactive but stays relevant.
I do not think we yet have dependency among health issues so I might
consider a brief duplication by entering under the pacemaker issue a
text cross-reference
"Staph bacteremia - see issue"
The AV-block does not need to be touched unless the pacemaker has to
be removed and replaced with some temporary treatment in between.
Just my 0.02 :-)
- [Gnumed-devel] terminology question, Sebastian Hilbert, 2009/04/02
- Re: [Gnumed-devel] terminology question,
Jim Busser <=
- Re: [Gnumed-devel] terminology question, Karsten Hilbert, 2009/04/02
- Re: [Gnumed-devel] terminology question, Karsten Hilbert, 2009/04/03
- Re: [Gnumed-devel] terminology question, Rogerio Luz, 2009/04/04
- Re: [Gnumed-devel] terminology question, Karsten Hilbert, 2009/04/05
- Re: [Gnumed-devel] terminology question, Karsten Hilbert, 2009/04/05
- Re: [Gnumed-devel] terminology question, Rogerio Luz, 2009/04/05