Re: [Gnumed-devel] Re: Cannot change the dates of the encounters

[Karsten Hilbert]

On Thu, Sep 04, 2008 at 05:43:31PM -0700, Jim Busser wrote:

> 1)  the identification and recording of when it was --- i.e. on what  
> year / month / date / time --- that a clinical event of interest had  
> occurred. Examples might include removal of a patient's appendix back in 
> 2002 (although we may not know the month or date) or the fact that the 
> patient was seen in the office or praxis yesterday, when it was so crazy 
> busy that I overlooked to record my progress note, which I may like to do 
> *now*. Clearly, I can have no objection that the EMR records now as the 
> date and time of my *entry* but have we a way to capture and display that 
> a visit occurred yesterday even though it is only being documented now?

Sure

- activate the patient
- document today
- start a new encounter
- document yesterdays notes under that encounter
- edit the encounter details to yesterdays date/time

If you don't document anything today you don't even need to
start a new encounter.

> 2) the datetimes when a single entry (or multiple entries) were written 
> into the EMR, where the one entry (or the cluster) got defined as 
> belonging to one single encounter, where each encounter is  
> chronologically distinct from every prior encounter, and from every  
> subsequent encounter?
I am not sure I get the question :-)

> I am almost getting the feeling that every clinical record needs not  
> only a datetime stamp for when it was written, but also a clinical  
> timeline entry which can default to current but which can be modified to 
> determine its presentation order.
Absolutely. We have implemented that for some crucial
things (like health_issue.age_noted or test_results).

Karsten
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