[Gnumed-devel] Re : Repetitive entry

[Vaibhav Banait]

Another solution might be to provide field above s/0/a/p where we can
create a list of templates, and make execution of abbreviation
expansion from the list itself. This would make it easy to remember
abbr. But this is global use of abbreviated expansion.
What I was suggesting was duplication of individual patient data in
follow up visit. What karsten suggested appear to hold true till
better options appear.

Regards
Vaibhav Banait,
Gastroenterologist,
Nagpur.
Ph: +91 98606 43436
-----Original Message-----
From: Busser, Jim
Sent:  15/05/2012 12:59:24 am
Subject:  Re: Repetitive entry

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



-- 
Vaibhav S Banait
MD (Med), DNB (Med),
DM (Gastroenterology),
Ph: Vaibhav:09860643436