Re: [Gnumed-devel] EMR tree display of allergy

[James Busser]

On 22-Sep-08, at 11:28 PM, richard terry wrote:

> On Tue, 23 Sep 2008 04:19:49 pm Karsten Hilbert wrote:
> I wouldn't be too prescriptive about this personally.
>
> A blank allergies textbox to me as a user means
> a) No allergies or
> b) No allergies recorded.
>
> As a clinician I would always say to the patient each and every  
> time 'Are you
> allergic to anything" or "I note your allergic to penicillin".

I was trying to be agreable with Karsten but must agree I am having a  
bit of a hard time to see the flow with proposed states:

Have you any allergies? The yield from the patient may be *one or  
more* among

1) specified (suspected or definite) trigger(s)
        - with or without description of consequence

2) can't remember what it was
        - with or without description of reaction

3) undisclosed *assuming* the patient would even *make* this  
acknowledgment

*** OR ***

4) an assertion by the patient that none exists (unless invalidated  
by a failed memory etc)
	--> this is really "none offered" which "may be none" and "may  
include unacknowledged undisclosed"

*but* less us get "real" here... it is the best we can do, and I can  
see people getting exasperated, we have already had "anal" jokes on  
this thread

So if we now consider the capture in the visit, any among #1-3 should  
prompt some entry of line items, and any entry of line items should  
automatically alter the allergy state from "unasked" to something  
else. The presence of anything but "?" in Caveat would mean that it  
had been asked at least (but possibly only) once. The presence of  
"phi" (none) would mean that at some point in the past, the patient  
suggested none, with no acknowledgment of withholding.

However the benefit of what is in Caveats is only for as long as it  
remains true and complete. Under this model, the asking would only  
ever have been done once. If we are to argue ongoing relevance (in  
future visits) the question would need to be re-asked each time. It  
is as if, despite that we already know *some* allergy information, it  
is in possible need of updating. So either it should be re-set at  
each encounter to be "unasked in this encounter", or we instead (at  
each prescription) offer up the allergy box in an easily-dismissable  
form.

So I am now of the view that the value of the "?" is limited to the  
initial documentation workflow (which may not get fully done at the  
inception visit) and if we mean the principle to have ongoing value  
we should prompt at prescribing or ordering anything that justifies  
allergy updating. The "state" could be set from unasked to none (if  
"none" was user-confirmed) and would otherwise be a state of +1 if  
anything was contained in the trigger / reaction lines. To be honest,  
the most important thing is that I had asked... I cannot see the  
value of separating "undisclosed" from "none offered".