Re: [Gnumed-devel] emrjounalplugin.py comments further html work

[J Busser]

At 2:30 PM +1000 9/13/05, Richard Terry wrote:
> Karsten et al,
>
> ...this time including all the soap
> stuff from one consulation into a single cell as opposed to the last one
> where one soap line gave a single cell.

Can we look beyond the single-problem encounter (visit) to consider 
how to handle something more complex, for I think that is where lies 
the challenge.

Suppose a patient comes in for an encounter, and they need
- diabetes medications revised, because sugars are running high
- diabetic foot care
- review of hypertension with change or reordering of medication
- review of lipids with change or reordering of medication

And suppose they have health issues of
- diabetes mellitus (control)
- diabetes mellitus (foot care)
- dyslipidemia
- hypertension

We could have
- diabetes mellitus (control)
S - Having trouble adhering to diet. Checking ~ 2x daily, staggered 
times, 9-13 mmol/L
O - Last A1C 0.09% ( is it under O we would comment on test results, 
or under A?)
A - Agrees to incr meds while continuing effort at wt loss
P - Incr metformin 500->850mg bid
     (using whatever trigger text would activate the medication list)

 - diabetes mellitus (foot care)
S - Noted slight drainage on socks past 3 days. No 
pain/red/fever/trauma but new shoes 7d ago.
O - (Details of exam)
A - Whatever
P - Whatever

likewise for dyslipidemia and hypertension

Richard may prefer to enter all this in a *single* SOAP note (maybe 
I'm wrong).  But under what Karsten has been proposing, the "parts" 
(dm control, foot care, lipids & hypertension) would each be 
encountlets  (encounter-lets) within one encounter.

So if the RFE originated from a patient saying "foot problem and 
refill BP meds" is this a single row RFE that gets attached 
unalterably to whichever issue the front desk or the doctor chooses? 
Is there a requirement that each encountlet have an RFE, or can we 
have a single RFE for the encounter?

In our display of what occurred in that encounter, if in the EMR tree 
we clicked, inside an issue/episode, onto a single encounterlet, we 
would presumably see only its parts (together perhaps with a shared 
RFE if it's possible).

RFE
 S1
 O1
 A1
 P1
 AOE1

However it is important that we be able to "see' the entirety of what 
occurred in a visit. So we would need a means of being able to select 
an encounter (meaning to include/display all encounterlets from that 
encounter).

And what form of display would be desired? A compact form
RFE
 S1 & S2 & S3 & S4
 O1 & O2 & O3 & O4
 A1 &A2 &A3 & A4
 P1 & P2 & P3 & P4

as well as perhaps the option of seeing the parts split-up:

RFE
 S1
 O1
 A1
 P1
 AOE1

S2
 O2
 A2
 P2
 AOE2 etc

Now here comes one extra part to resolve. The AOE. Maybe we are not 
required to have an AOE for each encountlet since we spoke of using 
(displaying) the A in cases where no AOE had been input - or is 
GNUmed in the event of a "null" AOE in fact copying the A into the 
AOE for *each* encountlet?

If not, would the user have an option of using a single AOE to tie 
together the parts into a synthesis e.g. new shoes / cellulitis / 
hyperglycemia / high BP (role of NSAIDs?)

Can the AOE be attached to the encounter without having to be 
attached to a specific health issue? Or assuming it nust be attached 
to *one* health issue, some ability to display AOEs *irrespective* of 
the particular issue to which it was attached?  We already employ the 
"gathering tool" of episodes "unattached to a health issue". But to 
add to the tree an issue line that gathering up all AOEs distorts the 
tree.

What about if instead, in the EMR tree,  we offer a toggle choosing 
whether to display by issue (as currently exists) *OR* switch to a 
tree of encounters as follows:

Encounter date/time
   AOE xcvxcv nbncxb bxnbcnx
   expansion triangle

under the expansion we would have the encounterlets that made up the 
encounter, and each encounterlet would be denoted by its issue name & 
assessment info (or AOE if this had been input down to the 
encounterlet level?)