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Re: [Gnumed-devel] Repetitive entry
From: |
Busser, Jim |
Subject: |
Re: [Gnumed-devel] Repetitive entry |
Date: |
Mon, 14 May 2012 19:29:24 +0000 |
On 2012-05-14, at 11:49 AM, Vaibhav Banait wrote:
> When you follow up a patients, how many times you find changed objective
> parameters. Patient with mole on face will continue to have it. The patient
> with copd will continue to have same findings with few differences. Patient
> with chronic liver disease will continue to have similar findings.
> This simply means, we unnecessarily continue to type same or similar data
> during consecutive visits.
> If the gnumed allows copying of previous visits data and then pasting and
> modifying it, it will save lot of time.
> Just a suggestion for may be a useful feature.
I know that the professional regulators (colleges and disciplinary bodies) are
very uncomfortable with copy/paste the previous and then change it, because
often not everything in a template was actually checked to the level of detail
that the template might imply. Also, it can be easy to miss to change something.
I would favour a solution in which the user can
1) select, from an inventory (a listing) of
findings statements
which one or many of them to be used, and
2) for these 'statements' to be able to support one or more fill-in
values
basically, what I would see developing is similar to what I have been doing
outside of GNUmed with my LaTex templates... developing them as a series of
distinct "bands" which are then combined (concatenated) as needed into a
variety of LaTex templates.
The limitation with what I have been doing is that my templates are not
customizable per-patient. The "bands" are combined outside of GNUmed and are
then "Load"ed into my GNUmed database but at that point I can only modify the
free-text placeholder content. I cannot, for example, choose to include or omit
allergies, medications, problem lists, vaccinations except by pre-defining the
content in the template.
A more flexible approach would permit the user to select which one-or-many
parts are needed for the report that is in question.
Adapting this to the present thread (and use-case), it would be nice to be able
to assemble a Physical Exam as a combination of user-definaable elements:
[ ] The patient was alert and oriented and in no distress.
[ ] General health appeared ???
e.g. excellent
good
fair
[ ] S/he was able to give a ??? account of problems.
e.g. an excellent
a good
only a limited
[ ] Weight was ??? ???.
e.g. 70 kg
154 lbs
[ ] BP was ??? / ???.
[ ] Pulse was ???
[ ] Head and neck exam revealed no neck nodes or goitre.
[ ] (head and neck free text)
[ ] Chest was clear.
[ ] (chest free text)
[ ] Cardiac apex and heart sounds were normal, no extra sounds or murmurs.
[ ] (cardiac free text)
[ ] Abdomen showed no scars, was non-distended, and had no palpable masses,
liver, spleen or tenderness.
[ ] (GI free text)
...
-- Jim