[Gnumed-devel] idea (Part 1) for improved narrative representations in EMR Journal and EMR tree

[James Busser]

*** This is a re-send of ideas I ran by a couple of people (off-list)  
last month ***
*** People may rather postpone comments to "Part 2" (the next email)   
***
*** where the ideas are re-worked to include EMR tree representation ***

************************************************************************ 
********

If we deconstruct a visit in which more than one issue was addressed,  
we know each issue-note can have been separately entered and saved.

Any "set" of SSOAP rows -- the first "S" being the patient request or  
"Purpose" -- is saved all-at-once, already.

Following a visit in which both URTI symptoms and Depression were  
addressed, it should be possible to see in the Journal entries (I  
suggest) of the following form

Encounter date

---------- Cinician (mod_when time)
S
S
O
A
P

iterated for each SSOAP in the encounter.
====================
as a separator for the next displayed encounter.

The set of notes for the encounter (where there was more than one  
within the encounter) could be preceded by "Encounter" formatting:

==============
<Encounter type> e.g. In office; In hospital; Residential; Voice;  
Email; Non-contact; Importer

*******************************************************************
The above approach would add the context information of which issue/ 
episode. If there is a concern that the author had not originally  
made the attribution that presently shows, because it was some other  
user who later re-mapped the relationship, then to instead use the  
AOE would still give context to the reader. This alternative approach  
would allow closer left-justification of the text, unless a majority  
feel the preservation of the left "columns" of Entered and Doc would  
over-rule the cost of width. It *could* look like the following, in  
which I have actually unwrapped the date into the encounter, since  
even if an encounter continued overnight, the subsort would also be  
on "time"

In office 2008-09-15
---------- LMcC (0945h)
S:   Flu?
S:   Dry cough, temp 38, rhinorrhea 4 days. Achiness but
       no distinct myalgia. Went to clinic yest. No Rx.
O:   T 38 BP 130/80 HR 96 reg Nasal congestion, pharynx
       non-exudative, chest clear, minor cervical adenopathy
A:   URTI, viral, presumptive
P:   Fluids, rest, hs codeine 15-30 mg x 4.

---------- LMcC (0947h)
S:   f/u depression
S:   Sleeping better, less tearful. No drug s/e
O:   Affect improved
A:   Responding to Rx
P:   Cont same dosage, r/a 4 weeks

Contrast the above with what we currently get in the Journal from a  
similar entry (below) and the difference in usability is clear.

.----------------------------------------------------------------------- 
-------------------------------
|    Entered |       Doc |     | Narrative
|----------------------------------------------------------------------- 
-------------------------------
| 2008-09-15 |      LMcC | ADM | Encounter: in surgery 2008-09-15  
04:47 - 04:47
|            |           |   S | Cough, dry. Sore throat. No fever. //
|            |           |   S | Flu? //
|            |           |   S | Episode: URTI //
|            |           |   O | Normal //
|            |           |   A | URTI //
|            |           |   P | Conservative //
|            |           |   S | feeling depressed //
|            |           |   S | crying, not sleeping. Boyfriend  
broke up 2 weeks ago //
|            |           |   S | Episode: reactive depr? //
|            |           |   O | mood low //
|            |           |   A | reactive depr? //
|            |           |   P | Consunselled. r/a 1 week //
`----------------------------------------------------------------------- 
-------------------------------

PS it is no criticism of the existing Journal, which I consider (like  
clay) to take a better shape from gradual re-working :-)

`----------------------------------------------------------------------- 
-------------------------------
Now suppose after the patient departed, you got a phone call from a  
lab that the patient actually had a throat swab positive for strep.  
You may add to the same encounter or you may start a new encounter.  
If you continued the encounter you are making post-hoc additions to  
what *had* been an in office visit, as the patient is no longer  
present. If you made a new encounter it could be displayed broken-out  
into a separate encounter "Non-contact 2008-09-15" however if the  
original encounter was extended it could be like:

=================================
In office 2008-09-15
---------- LMcC (0945h)
S:   Flu?
S:   Dry cough, temp 38, rhinorrhea 4 days. Achiness but
       no distinct myalgia. Went to clinic yest. No Rx.
O:   T 38 BP 130/80 HR 96 reg Nasal congestion, pharynx
       non-exudative, chest clear, minor cervical adenopathy
A:   URTI, viral, presumptive
P:   Fluids, rest, hs codeine 15-30 mg x 4.

---------- LMcC (0947h)
S:   f/u
S:   Sleeping better, less tearful. No drug s/e
O:   Affect improved
A:   Responding to Rx
P:   Cont same dosage, r/a 4 weeks

---------- LMcC (1545h)
S: lab phoned culture results
S: throat swab from clinic grew Strep species
A: Strep pharyngitis
P: Contact patient

---------- LMcC (0005h)
S: patient callback
P: information relayed, recommendation made for abx
    Rx Pen V etc phone to Shopper's Drug Mart (Arbutus)
=================================
In office 2008-09-22 (next Encounter etc)

If any Encounter would continue across midnight, its component  
entries would still sort properly. Their sequence (chronology) would  
be respected and, if desired, we could expand the clinician timestamp  
from

---------- LMcC (1625h)
to
---------- LMcC (0200h [2008.09.16])

--> see next email (Part 2) for a further re-working of the above