Re: [Gnumed-devel] encounter edit before final save

[Karsten Hilbert]

On Wed, Aug 13, 2008 at 05:23:30PM -0700, James Busser wrote:

> Supposing a doctor sees a patient who may have a viral URTI or  
> bronchitis or pneumonia.
>
> Suppose the doctor had the benefit of an X-ray service within the  
> building and therefore chose not to document a formal plan until after 
> getting a quickly-available x-ray. The doctor might in this situation 
> create a partial progress note
>
>       S (symptoms)
>       O (findings)
>       A  viral URTI / bronchitis vs pneumonia - need CXR

Personally, I *would* formalize the plan as "referred to
X-Ray" unless it is truly adjacent to the exam room because
the patient might decide to leave w/o coming back or before
having the X ray taken. But, yes, a doctor may decide to do
as you say, no problem.

At other times I might embed in findings an "auscultation
suggests infiltrate (needs CXR)".

> If the doctor exercised the option to minimize the current instance of 
> the GNUmed client, essentially "pausing" this note until the return of 
> the patient, they could revise the "O" to be:
>
>       S (symptoms)
>       O (findings +) CXR normal or infiltrate or ...
>       A (assessment that is now assisted by the X-ray result)
>       P (plan based on the above)
>
>       admittedly the medical action of sending the patient for the x-ray has 
> been buried in the "O" however especially if a doctor was not yet  
> ordering in GNUmed they may wish the flexibility to make their entry in 
> this fashion and it is nice to not overly constrain what can be a  
> judgment decision by the clinician on how to document.
Absolutely.

> Is there however a 
> caveat with respect to a "timeout" after which the database will not 
> allow the paused instance to write into the backend?
There is, at the purely technical level.

> Where and how would this configuration be set?
The TCP/IP stack timeout is one place I can think of.

> If instead the doctor exercised the option to make 2 notes within the  
> encounter, it might go like:
>
>       S (symptoms)
>       O (findings)
>       A  viral URTI v bronchitis v pneumonia
>       P CXR
>
>       O CXR shows infiltrate (verbal from radiologist)
>       A Pneumonia, community-acquired, not severe
>       P Patient counseled. Rx... Return in ... If deteriorates...
>
> a few questions now:
>
> 1) after committing the second SOAPlet (the OAP) would GNUmed presently 
> display within the encounter:
>
>       S (symptoms)
>       O (findings)
>       O CXR shows infiltrate (verbal from radiologist)
>       A  viral URTI v bronchitis v pneumonia
>       A Pneumonia, community-acquired, not severe
>       P CXR
>       P Patient counseled. Rx... Return in ... If deteriorates...
>
> or (maybe better)
>
>       S (symptoms)
>       O (findings)
>       A  viral URTI v bronchitis v pneumonia
>       P CXR
>       O CXR shows infiltrate (verbal from radiologist)
>       A Pneumonia, community-acquired, not severe
>       P Patient counseled. Rx... Return in ... If deteriorates...

To tell the truth, I don't know at present. However, it is
easily changeable when it becomes a problem.

> 2) later there may come a document -- the official report from the  
> radiologist -- which would be added via the document viewer. Addition of 
> the document would create a new encounter, correct, of type ??
Not necessarily. If I haven't yet started a new encounter
for said patient it would be listed under the initial
encounter. Even if the radiologist herself implanted the
document into my GNUmed database her client will (ask her
whether to) attach to the currently running encounter (based
on the encounter timeouts). In that case two providers would
be accessing the same patient within the same encounter
concurrently.

If the X ray is taken, say, the day after, the radiologist
may with good reason start a new encounter (of a type of her
chosing). The document will then be attached to *that*
encounter and to ...

> The doctor (or assistant) should wish to associate it to the episode in 
> which can be found the encounter (or encountlet) above.

... whichever episode seems prudent (IOW, the one created
the day before as "?pneumonia").

> How would the new encounter (which represents the addition of the  
> radiology report) appear in-line below the above-described and listed  
> SOAP rows, for example in the journal?

If it's a new encounter happening later than the initial
exam it'd be listed below in the journal. In the tree it'd
be listed atop.

Karsten
-- 
GPG key ID E4071346 @ wwwkeys.pgp.net
E167 67FD A291 2BEA 73BD  4537 78B9 A9F9 E407 1346