[Gnumed-devel] help on encounters

[Jim Busser]

I have gotten stuck on a few aspects of "encounters".

Easiest is if a patient books an appointment (a sample encounter) in 
which one problem is being dealt with. This encounter has a purpose 
(the RFE), provides for a SOAP note, in the simplest case having one 
clin_narrative row for each SOAP element, and an AOE.

Now

- in the schema (as it exists, or as it is yet to be updated) are the 
RFE and AOE each clin_narrative rows with a value for soap_cat other 
than {s,o,a,p} or is this value left null so that we will have is_rfe 
and is_aoe?

- we have resolved that an encounter need not have ALL the above 
elements (for example a phone call may have no "O" unless the doctor 
wishes to note something about the patient's affect, speech or sounds), 
but do we wish to assert any to be REQUIRED i.e. as a precondition for 
creating an encounter, must we have at least an RFE?

- supposing at the end of the visit, or even a week after the visit is 
done, there is a plan or request by the patient or doctor for followup. 
I can understand that there is now a new RFE but I do not understand an 
attachment to the visit that has already concluded. The RFE will relate 
to the next visit, i.e. to the next encounter for this health issue. We 
are not proposing for a single software "encounter" to refer to 
multiple visits, are we(?) for I thought that was a functional aspect 
of the "episode".

- supposing before this next visit (which may not even be scheduled 
yet), the doctor wishes to record a discussion with a consultant. I can 
see how the discussion could lead to a modification of the Assessment 
and/or of the Plan but how to handle this? Add two new clin_narrative 
rows, linked to that last encounter, so now the encounter has 2 As and 
2 Ps? It would seem better to create a new encounter to capture this A, 
P and updated AOE with an RFE that could be "discuss with cardiology". 
After all, if we bother to create encounter types of "chart review", 
then we should create a new encounter to capture the discussion with 
the consultant, along with any resulting modification to the assessment 
and plan.