Ok so I´ll try to explain how I am using so far GNUmed and the way it stores my patient data:
*** I am not currently connected to a GNUmed DB so the terms in English could be messed up.
1st Visit) Patient gives name and DOB and tells why she came to me
- back pain.
-- ) Put "I have back pain" in the RFE field
-- ) take family history if any -- FUNDATIONAL HEALTH ISSUE = "Family History" with multiple --notes-- one for each problem that is relevant (precocious CVD, genetical issues, Cancers, etc..)
-- ) take personal history -- ONE FUNDATIONAL HEALTH ISSUE PER PROBLEM = Hormonal Birth Control, Skin Problems, Osteo-Muscular problems, etc... AND a ISSUE called "Back Pain"
-- ) Start to colect the SOAP
-- ) Enlist all Measurements that are of note (I sometimes also put the REALLY important ones in the sOap field - so you can see them the next time you see the patient when you click on the open encounter view of the Note applet)
-- ) Define the Summary of the visit (here I think I start to get in some problems with the design) as " First Visit, Back Pain , asked to do this and that and return in 2 weeks"
2nd Visit) Now 2 weeks pass and patient is better but not 100%
-- ) Click on "Back Pain" in the Note Plugin, new Note has "Back Pain" on the title.
-- ) RFE = " Better but not 100%"
-- ) SOAP
-- ) Summary = " Better but not 100%, start acupuncture and return weeklly for 1month" ** ;) my free on-list merchandising ;) **
-- ) Save = GNUmed asks if I want to close the new or old (see ??? - I am thinking a little different of the design, because it seems obvious to me that if it was supposed to work the way I am doing things the client would not ask me nothing ;)
*** on the way out patient says "Oh doctor, I want to discuss also my Birth Control Method"
-- ) Click on "Hormonal Birth Control" and a new Note opens.
-- ) RFE = Birth Control Guidance
-- ) SOAP
-- ) Summary = Changed Birth Control method to Hormonal Pills with Drosperidone and only 4 days off = "Yaz"
-- ) Save
________________________________________
3rd Visit) one week later patient tells us she is better form back pain after last acupuncture session, seems 100%
-- ) RFE = Better, maybe 100%
-- ) Click on "Back Pain" - new note is created
-- ) SOAP
-- ) Summary = "Better seems 100%"
-- ) Click on "Hormonal Birth Control"
-- ) SOAP
-- ) Summary = "All is fine with 1 week use"
Save ______________________________________
Any thoughts?
You see my method of using GNUmed is a Problem --> Visit paradigm.
Please feel free to enlighten what you think could change for easier use :)