Is there a way to insert the results of your current history and problem list/ medication list tables into your current visit specific notes. This would be helpful as a snapshot of the current problems you are listing as you care for that specific days issues. Later as you update problem and medication lists, they may not reflect what was going on at the time of the past visit. That would help keep you from duplicating effort to update your lists and then document those same issues in your progress note for that visit.
Dr Bowen, displays the Patient Report (top left of the patient summary page) selects only the History part, then cut’s and pastes that into the 'Speech Dictation Form" or a similar textarea form.
-Tony
Thanks, I was able to make that work. That seems a little round about and bulky though. It seems the history data is updated with a new database line (history_data) at each entry change, so you have a dated documentation of each of those changes. The problem lists however (lists) are each an individual data base line. It looks like one of the contributed forms pulls some of that information (plist) into boxes on a form, so it seems like it would be possible to perhaps create a form to automate that. It seems that currently to document a complete adult physical you have to fill out the history data area, create allergy,problem,surgery and medication lists, fill out a chief complaint and history of present illness data box, fill out a review of systems form, and then fill out a physical exam form. (5 seperate areas, 6 if you want to write a plan of care at the end in a dictation box). I think it would be much more efficient to have all of those as a single form that interfaced with your history and problem list data. A layout based form doesn’t seem capable of doing that, at least as far as I can figure out. Previously I performed all of these functions on a two page word document form and printed it for my charts. I can save that as text and cut and paste it to a dictation box, but it does not perform the needed function of creating your problem list data for ongoing care unless you repeat that seperately. That kind of documentation could also help improve coding justification for other visits to be able to bill insurance at a higher level as justified by the work you actually do for the patient without worrying if your documentation is adequate. I am a doctor and not a programmer, but I am finding this kind of fun to work on. Any input would be helpful, and if I can figure out a form to do that eventually, I will try and post it in the form contribution area. The only current form there, which is a physical form, doesn’t seem to work in windows though.
Cverk: did you solve the problem?
That is exactly what i felt the oemr is missing. As a consultant, i always write full H&P on every visit. I just couldn’t figure out why oemr is not set up to have full H&p note as template.
If i copy paste all each section, it loses purpose of emr system. I can do this easier with word document and use that as my emr system. The emr system should be able to pull information available on system, eg) past medical hostory, social history, family history, lab, my previous assessment and plan with one click into the progress note of visit day. All i should do is fix HPI, edit assessment and plan and save and print or fax.
Since all data is already available in emr, it is matter of linking that to one note and then save that note.
When i didn’t see standard progress note in American medicine is not available, i started to question if there are enough American doctor who is using oemr.
Shouldn’t you be able to corelate an issue with an encounter as shown in the EMR manual ?
>Associating Issues with Encounters
The far right column in the Issues list represents the number of encounters associated with a given issue. Click
on the ‘0’ next to a newly added issue to bring up the ‘Issues & Encounters’ dialog.
Also, I don;t think it is advisable to copy information from another field but instead make a reference to the location of the source of the information. The principle is to ensure uniqueness of data in the database. Otherwise, if you change the information on the source then the information on the copy is now different.
But it might be a good idea to have multiple tabs inside of OpenEMR instead of just the Top and Bot as I find it useful to have have windows (lightboxes) open at the same time so I can complete a task looking at information from all those open tabs. I wish OpenEMR can do this !
The ability to import critical portions of the patients history and physical into a standard H&P format, and to clone that information from past visits is not readily available from the current basic patient visit interface. There are many who agree with you that this functionality should be part of future versions, but recently the bulk of programming energy has been directed at attaining MU certification. Many of those features are currently available by mastering the CAMOS interface
and you should play with that some while we wait for the financing and energy to “improve” the patient visit interface. (Please read my comments below.)
Thank you for your interest in OpenEMR and for asking these necessary questions. Your input as a practicing physician is critical to the future of the project.
@JP
It is not enough to treat the patient visit display as a liked database. The information that the physician uses to treat the patient must be ALL be displayed on that page as the physician is seated with the patient. That page should also contain the necessary links to order tests, prescribe treatment, arrange followup, make referrals, and send routing information for billing. I have posted about this previously and I am glad to drag this topic back to the forefront again. I would welcome your thoughts and comments.
I think it was Dr.Cahn that posted a proposed mockup a while back that looked very good for this issue. I can see how meaningful use is important on so many levels to make this project a real player, but I am not sure the federal government really has a complete handle on the parts of this that promise to make us better doctors. Simplified documentation and transmission of information this way is something that can make for better medical care, and I hope it gets some traction. Maybe the nonprofit OEMR organization should be the group selling the various fee based plugins like e-prescribing to create a resource stream to develope this kind of thing. Perhaps a menu of the lowest cost options for e-prescribing,hosting,billing services,credit card merchants,portals, online forms etc. could produce development and marketing capital that could make this project a dominant player. The current situation of 300-400 proprietary and expensive systems out there just begs for a gold standard.
Dr Cahn,
I read your original post and i agree with you 100% and the picture you drew on the original post is exactly what i want as well. I will pay for that!!
Unfortunately, at this time after three months of opening practice i spent all my savings and making as much as what my medical assistant is making, for entire day, i probably make what programmers charge in an hour. Haha
I spent money like millionaire trying to set up practice and start couple of project, and as you know, whenthere is “medical” wording, everything get 6-10 times more expensive (eg, medical stool chair $450 which you probably get regular stool gor $45.
Anyway, my point is i cannot pay to hire a programmer to program this note but i think this is something every currently practicing US physicians need. So, if we can get good number of physicians chips in some money to have programmer to build one would be a good choice. And i am certainly willing to pay what i can for little money i make. Once the note is built it can be resold to further so, may be we can even find a programmer who can do this at low cost as well. “everybody” share some cost of it.
Can any programmer able to give some figure of how much they can reasonably do this for?
And any physician who is willing to share some of the cost?