Medical records - where and how

OpenEMR Development
1

nahoj1976 wrote on Saturday, August 13, 2005:

Hi.
Some more questions for my understanding:

1. title-words
In Sweden most medical records are written in the form:
title-word       text

That form makes it easy to find information for example about the heart - just look for the title-word heart.
Is there anywhere in openEMR that one could put in information in that form? Or do I need to create a new form for this?

2.
A lot of notes I make will automatically have the current date linked to it. Is it possible to change this so that I can select what date the note should be linked to? (In Sweden we often dictate our notes and a secretary write it in on the date it is dictated. After a long week-end being on duty it might differ a week between dictation and writing).

3.
Where do you write admission notes (Dr letter of introduction) in the system? And where do you put the letters of admission You get? Is it put into the documents folder? But if so: how do one keep tracking of the date sending the admission notes and getting answer? (In this bad-functioning medical system of Sweden it is not seldom the patient has to wait 1 - 1 year before they will come to the hospital where I send the admission notes, and then it might take another 3 - 4 month before I get an answer.  Keeping track of admission notes therefore is quite important in Sweden…  )

4.
Is it possible to instead of ICD9 change and get ICD10? And can one put in ICPC-2 (created by Wonca) as classification into openEMR?

/Johan

2

drbowen wrote on Tuesday, August 16, 2005:

Dear Johan

"title-words – In Sweden most medical records are written in the form: title-word text"

Makes sense to me.  I was always taught to write in full sentences.  Your suggestion would make text a lot more searchable.

Rod Roark, I believe is working a system to allow this type of linking by diagnosis.

"A lot of notes I make will automatically have the current date linked to it. Is it possible to change this so that I can select what date the note should be linked to? (In Sweden we often dictate our notes and a secretary write it in on the date it is dictated. After a long week-end being on duty it might differ a week between dictation and writing). "

I believe that you can change the date of the encounter on the new encounter.  I think this option is only available at the time of creation. You may have noticed that there are two date fields at the new encounter form.  I believe the first date field is to do exactly what you ask.

"Where do you write admission notes (Dr letter of introduction) in the system? And where do you put the letters of admission You get? Is it put into the documents folder? But if so: how do one keep tracking of the date sending the admission notes and getting answer? (In this bad-functioning medical system of Sweden it is not seldom the patient has to wait 1 - 1 year before they will come to the hospital where I send the admission notes, and then it might take another 3 - 4 month before I get an answer. Keeping track of admission notes therefore is quite important in Sweden… ) "

The system works somewhat differently here. I think you refer to a referral to another physician who takes care of the in-patient work? A hospitalist?

I do my own in-patient admission work.  I prepare a compreensive office visit, similar to an annual office visit. I then print out this note along with the medication list, problem list, allergies, surgeries and then a review of system.  This is sent with the in-patient orders with the patient to the hospital.

"Is it possible to instead of ICD9 change and get ICD10? And can one put in ICPC-2 (created by Wonca) as classification into openEMR? "

It should be relatively simple to dump the ICD-9 codes and then load with ICD-10.

On ICPC-2, I don’t know.  Its not something that we use here.

Sam Bowen

3

sunsetsystems wrote on Tuesday, August 16, 2005:

Regarding billing codes, I have recently added the ability (currently only in cvs) to use different coding methods.  See custom/code_types.inc.php.

Also in cvs, the ability now exists to associate medical problems (and other issues) with specific encounters.

And changing the encounter date is now something that can be allowed or disallowed for individual users if you install phpGACL.

– Rod (http://www.sunsetsystems.com/)

4

nahoj1976 wrote on Tuesday, August 16, 2005:

Thank you, Sam and Rod, for your respons.

My questions might look odd for you, but my approach towards openEMR is from another side than your, I guess.

When a patient come to me the consultation is done in a structured manner in order to be effective:

1) The reason for him/her to search Dr.
2) The history. (The patients subjective description of the problem added with the answers of my specific questions)
3) An examination of the patient
4) My assessment based on the combination of the history and examination.
5) My measured actions in order to help the patient (Which could be anything from prescription of medicine, surgery, referral to another physician, etc, etc)

I am sure You are working quite similarly. I like to have the medical record put in the same logical way. I found the module SOAP that is partly built up in this way but where it is not possible to change the date of service.

After a few years the same patient have come with the same problem quite a few times and then one might like to collect all the times this patient come with for example cough. That could in a typical Swedish medical record be done by 2 different means:
1) The medical records are divided into different segments and each segment has its own title (for ex. ‘Lung’)
2) The medical records are divided into ‘problems’ that the patient comes with. (For example at one visit a patient might have problems with an urinary tract infection and cough. They are put under different titles.) This latter structure is more often used in primary health.

To make it even more complicated one might have both structures nested into each other…

I think the SOAP-module would be quite easy to adjust by adding two things:
a) A problem-tag that could make the records searchable and filtered.
b) A possibility to change the date of service for them.

If one would like to use structured titles following a defined schema then one needs to add a sql-table with the title-words one wants to use and that I think is a larger work to do (with all the things around when adding a table).