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Re: [Gnumed-devel] automatic episode naming
From: |
Karsten Hilbert |
Subject: |
Re: [Gnumed-devel] automatic episode naming |
Date: |
Thu, 8 Sep 2005 16:11:31 +0200 |
User-agent: |
Mutt/1.5.9i |
Richard,
I enjoy this discussion. It shows why it's useful that we
keep working together despite our differences in approach.
1) I disagree that there should be progress notes that are
not linked to an episode/problem (but see below).
2) I fully agree that this linking should not at all unduly
impede the doctors' workflow.
> > 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.
Note that this was the agreement with Ian. I seem to
remember him saying you agreed with him on that. I may be
wrong.
Personally, I am OK with enforcing a non-empty progress note
only. I see the merit in enforcing an RFE, too, however. In
my daily practice it wouldn't even make a difference.
Because I could automatically use as an RFE whatever the
patient tells frontdesk staff (this will in some cases be
totally inaccurate, I know).
Maybe other clinicians can speak up here ?
Would you suggest enforcing progress notes to have a
non-empty line in *any* section or a, say, non-empty plan
line ?
> I disagree about the enforcement stuff, and I don't beleive every time the
> patient sits before me one needs to 'name' the encounter.
I agree it should not be necessary to *manually* name the
episode(s) the progress notes should be linked to. Enforcing
the linkage is just Good Data Practice.
> 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 agree.
> I do beleive the option should be there for the doctor to add a
> summary tag
...
> 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.
Sounds right to me. I have added this to my personal TODO
list. We even already have a field for that in the backend:
clin_encounter.description
Currently it just holds something like
"encounter auto-created then-and-then".
Karsten
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