[Gnumed-devel] Appointments, records of care, and the capture and eventual storage of services as billable items

[James Busser]

The following questioning is maybe picking up after

        http://lists.gnu.org/archive/html/gnumed-devel/2004-07/msg00037.html

I am doing a bit of a mental walk-through as one goes from an  
appointment, in which a patient may want one or more things to be  
done, to the medical record, that needs to capture what has been  
done, and the ability to bill, though that is deferred until we sort  
out the earlier stuff.

I am thinking that appointments are not themselves clinical... they  
are really just "reservations" for encounters, and some information  
about what needs to happen in the encounter may already exist because  
of leftover items (or a plan) from a previous encounter, or may exist  
as a result of other information that was received about a patient  
(i.e. would be an action item arising out of a non-patient contact  
encounter) plus any things newly wanted by a patient.

Appointments (reservations) would be for:,

- one or more patients
- one or more providers
- we note that a multi-patient (and/or multi-provider) visit type  
could expect multi-bookings
- a specific date
- a specific time (start time) -- except if the time is left blank  
pending a "fit-in"
- often, a planned duration (which is translatable to an end time)
- a location (because the doctor may see a patient at the patient's  
home or other locations)
- a particular exam room may also need to be specified

Now here comes the trickier part. The appointment will be for one or  
more things to be assessed and/or treated. The appointment must  
expect (and may have to facilitate) one or multiple professional  
services (evaluations, procedures and treatments) and may also  
require that certain equipment or supplies (things like PAP smear or  
microbiologic specimen swabs or vaccines) be available.

This has implications:

- the nature of the one or more things that need to be evaluated or  
done will determine the total length of time and other dependencies  
needed for all items to be fully completed

- what *was* completed should be captured in or at least *with* (or  
linked to) the encounter. How might this relate to the sOaP parts of  
the note? A certain type of physical exam like a Folstein mini-mental  
exam and/or a sigmoidoscopic exam or a pelvic exam with speculum and  
PAP test could be coded to the sOap row --- though we do not yet  
provide for this --- and a treatment like a vaccination or the fact  
the counselling or education was done and/or consent obtained into  
the soaP (Plan) row --- but again we do not yet provide for this. The  
schema so far provides only for:
... types (like history, family history) to be linked to soap rows and
... diagnostic codes to be able to be linked to soap rows of type  
"A" (soAp)
but if we agree it is useful to be able to see or figure out or query  
whether and when certain things had last been done, how is that best  
structured? I know that we planned that if a prescription were  
written, the clinical note would capture some representation even  
though the prescription itself gets built from rows in a medication  
table. So should "things" that have been done to patients, such as a  
major or minor consultation, various kinds of examinations and office  
procedures, be stored in a "what was done" table? There does exist an  
"operations" table but maybe it is not intended that office  
procedures be included, and maybe some should, for example an office  
vasectomy.

- there is also what was *planned* (in previous notes) or *wanted* by  
the patient to be done, but was not completed at this encounter, and  
will have to be completed later, along with any newly-added plans  
from the current encounter, and these things therefore need to be  
able to exist and be managed in a way that helps them to get actioned  
without the future appointment having yet been made