Re: [Gnumed-devel] Fwd: [Elkg] Info qui peut servir

[James Busser]

I seem to be receiving email OK but cannot send so am careful to keep my outbox 
empty to hopefully avoid flooding the list. Unfortunately having to send by web 
mail 
(copy-paste). PS will be taking next week off. Herein my post:

On Jul 29, 2004, at 3:20 AM, Dominique Buenzli wrote:
>See http://hherb.com/cgi-bin/twiki/view/Gnumed/CountryNotes

Noted

>Not sure if it is the right place for it, tell me if you would like to put it 
>elsewhere.
>depends what we are intending

I created that page to hold some information that I acquired pertinent to 
getting 
local pathology, radiology reports etc into gnumed

right now the page is free-form

I was thinking to put anchor links at the top of the page each time anyone adds 
a 
country (or location within country). For example, what I wrote may not apply 
outside the province of british columbia so as soon as anyone adds info 
pertinent 
to, say, Ontario or Quebec we can add that nested level to the anchor links. 
Maybe 
what I am describing overlaps with "localization" but "Country Notes" seemed 
clearer.

I was further thinking that as soon as any one's country notes grew enough, 
that 
content could be split off onto country-specific pages (but still linked from 
this 
main page).

>give the gist of what's different/important to Swiss
>practitioners and attach the appropriate URLs (deep-linked,
>perhaps ?) ...

Most of what Dominique posted seems seems not country-specific - rather, a set 
of 
design and functional requirements that are being presented.

Notable however was the content in one of the links abstracted below, in which 
they 
discuss health issues, encounters, episodes. I found very helpful their term 
"subcontacts" referring, within any one encounter/contact, to the bits that 
pertain 
to any one issue in a multi-issue contact. I did not quite understand how they 
differentiate a contact "which may or may not have an encounter", maybe have to 
read 
it over again.

Early in the document they suggest that while in SOAP the P is traditionally 
"Plan" 
they propose it be used for Procedure or Treatment. In their examples, P is 
used to 
contain the procedures/treatments that are done/prescribed/initiated/requested. 
Seems to exclude ? and contingency info. Maybe that is captured in their Health 
Approach.

They also seem to couple the SOAP note to "Services" e.g. anamnesis, clinical 
exam, 
lab request, Rx results, Rfe

Cheers --- Jim

http://www.health.fgov.be/telematics/label/mh/struct/structuration_epr_2003.pdf
from Appendix C, page 30:

Definitions of the concepts as used in the Belgian quality labelling process 
for 
GP’s software:

Health Care Element: A Health Care Element can be defined by any item in the 
patient 
record describing the patient’s state of health and for which something is (has 
been/will be) done by a health professional. A Health Care Element is addressed 
by 
at least one Service. A Health Care Element is related to one defined patient 
and to 
one specific problem (item). Most of the time, this problem (item) can be 
identified 
by a diagnosis, by a patient’s complaint, a risk factor, a life condition

Health Approach: A Health Approach encompasses all what has been (will be) done 
by 
one Health Agent with a specific objective for only one Health Care Element.

Contact: A Contact is any interaction between a professional and the EPR, with 
or 
without an encounter. It includes at least one Service (i.e. it adds something 
to 
the EPR). A Contact is related to only one Health Agent.

SubContact: A SubContact is a part of a Contact dedicated to one and only one 
Health 
Approach. It includes all the Services of a Contact related to the same Health 
Approach. All the services of a SubContact are thus related to the same Health 
Care 
Element.

Service: A Service is the recording (data entry) into the EPR of information 
related 
to any activity or process performed by the health professionals. Any data in 
the 
EPR is introduced through a Service. A Service is related (directly or 
indirectly) 
to only one Health Agent. A Service may be related to several SubContacts (of 
the 
same Contact), and thus to several Health Approaches (of a same Health Agent) 
and to 
several Health Care Elements (of a same patient).

Health Agent: A Health Agent is a professional (or group of professionals) 
responsible for the content of a Health Approach. A Health Agent is a Service 
producer.