How can one enter encounter-specific diagnoses, preferably using ICD9 into the medical record in a way that it is
easily seen by physician during subsequent visits and is reflected in the syndromic surveillance report?
Does this report discriminate between issues and such diagnoses?
I suppose you are enquring about linking an encounter with the problem issue. For that, in Patient/Cient->Create Visit, Click ‘ADD’ to add an issue and link that issue with the encounter by selecting the issue and save the encounter.
For the diagnosis code to be shown in syndromic surveillance report, in
Administration->Services , edit the desired code and mark it as Reportable.
With some customization in the code, you can discriminate the issues and encounter specific issues in the syndromic surveillance report.
I guess I was looking at problem issues differently, maybe guided by the examples already given with the initial install e.g. asthma, hypertension. I was considering them necessarily chronic issues that span multiple encounters.
From that point of view, I was therefore imagining that there could be another way to capture an acute, one time illness e.g acute respiratory tract infection as, say part of an encounter form. e.g a form with: chief complain>history>physical exam>review of systems>diagnosis>plan. or somewhere within the SOAP encounter form, we have diagnosis. This diagnosis is searchable within ICD9 codes. This will more closely simulate real life physician flow of ideas.
I am unable to find such a form and, i suppose most contributed forms might not integrate well with other OEMR functions including reporting.
If there isn’t a way, I guess I will just heed your advice and use the problem issues screen for all kinds of diagnoses and link them to encounters as described.
Ahoy,
I agree with Mukoya that there should be a better way to record a visit that reflects the physician’s “thought-flow” during that visit. Some, but not all of this can be with CAMOS. In particular the doc should be able to enter an assessment in the visit note that is ICD 9 or 10 specific and that would automatically transfer to the fee sheet, route slip, billing function, what have you. Right now that appears to link backwards. And the assessment should allow for a comment at the same time - e.g. 1) DM type 2 250.00 HgbA1c dropping as expected.
Likewise prescribing, labs, imaging, referrals, and other treatments should flow from the “plan” portion of the encounter and not require a jump to a summary page, dashboard etc. I have commented on this before and Brady concurred that the encounter needs to better reflect the actual flow of ideas. I don’t really see the solution as a LBF; the process of recording the encounter or visit needs the capacity to capture these discrete data. And I echo Mukoya’s plea that information be presented in a customizable order in the note ( though I would have the ROS before the PE). The right side drop down menus can already be modified to accomplish some of these ideas. My two cents from a non-coder. Thanks.
As observed, though beautiful LBFs can be created, data entered in this forms is often not captured in other modules of the program and -at least I- am unable to link icd9 codesto the forms. CAMOS also has limitations regarding this though it can be quite handy if used to its full potential.
Anyway, despite not being a developer, I partly appreciate challenges encountered by coders of Open Source projects and I am confident many of these issues, as long as we keep raising them, will be eventually addressed.
I am in the process of developing a system for capturing clinical encounters in a more structured format than LBF. The resulting representation in the database is a tree of items. So in the physicians’ Assessment and Plan, he can create an entry for DM 2 250.00 and the create subentries exactly as you describe. So in the A/P the note looks like this.
-1. DM2 250.00
-HgbA1c dropping
-Repeat A1c in 3 Months
-Continue Metformin 500mg BID
Each of those 4 individual statements is captured as a row in my “document entries” table, and the 3 sub items are linked to the initial problem entry in the database. (The problem statement owns a collection of it’s subentries.)
I’m still relatively early in my implementation. However, the linkages to other sections is something I’m working on. For example, when the physician adds a problem to his A/P. Right now, I’m creating both my document entry and also automatically creating an entry in the list table as if an entry were added using the current “Manage Problems” interface.
Other issues that have been raised here include procedure orders being printable, locking patient notes for editing (even by his provider) after a period of time, say every midnight, et.c.
Will keep our eyes open for when it is ready for commit.
I just got a demo from a Dr that added encounter edit locking after signoff with a 36 hr time out on the doctor as well. I’ll see if they can get me the code to share.
-Tony
I am not sure that I made myself clear. Yes, the hierarchy of plans linked to assessment is excellent. What I am suggesting (to everyone) is that the entries in Assess: and Plan: are in part discrete searchable database entries. To further expand your example:
-1. DM2 250.00
here originates from 1) a click on the problem list entry
or 2) a search box linked to the ICD-9 table.
is associated with today’s visit in the database and auto populates the fee sheet
-HgbA1c dropping
-check today
is selected from the lab order menu and note goes to nurse for in-house lab
-check , today
, are selected from the lab order interface and sent to nurse and to LabCore via two way interface
-Repeat A1c in 3 Months
is selected from the lab order menu and is loaded in the patient’s tickler/reminder file.
-Continue 500mg BID
e-RX interface is opened and defaults to this patient and to order refill.
selected from drop-down of pt ed materials and printed for pt
-Return
goes to the checkout desk
or brings up the calendar on my screen and the appointment in made printed for the patient.
Now I can move to the fee sheet to accomplish the administrative tasks.
OK? Now I have a powerful tool that gets all of my plan done for the patient without jumping to other pages in OpenEMR to accomplish that. I have documented the entries needed for lab, pharmacy, (x-ray), (referrals), etc and I have done this in a couple of minutes in the same way that my brain is accustomed to working for good patient care. Wait 'til your brain is 63 y.o. and you’ll appreciate how necessary this is to prevent neglect of important parts of the plan of care. This is patient centered care IMHO and OpenEMR needs to be the tool that drives that.
Jack,
That is exactly what I envision. Making the clinical note the central interface for all tasks, such that clinical documentation can be easily linked and connected to ancillary “administrative task.” My system for hierarchical data entry is the just the beginning. Being able to structure data so that the system can understand it well, but not being so restrictive as to hinder the clinician is a tricky problem.
I wonder if any of you have looked at the clinical descision rules engine that we (Brady, MI2 and Ensoftek) are actively working on, this tool is the basis for what you are discussing here as well as a model for reminders and Clinical Quality Reporting.
See: http://wiki.oemr.org/wiki/Clinical_Decision_Rules
One other issue: Is display of abnormal procedure results going to be addressed by CDR? I have noticed that where discrete results are designated normal or abnormal, there is no way of the abnormal result catching the eye of a physician. For example, in the list of issues, active problems/issues are displayed in red while inactive are displayed in black. Can the same be applied to procedures? Already, I think the “Procedure Abn” list with default “Yes, No, High, Low” can be a basis for a coloring scheme.
A step higher may be a customizable setting that allows individual numerical discrete results ranges to be set with different colors e.g low HB from 12-8 g/dl could be orange and less than 8 red e.t.c. The laboratory could also “grade” non-numerical results as, say, severe or mild abnormality or based on urgency of intervention necessary. These then could be displayed in different colors.
Alternatively, a popup for a registered severely abnormal result once patient chart is activated could be implemented.
mukoya,
Not in the works for CDR; goal right now is to get MU requirements met. This stuff will likely get dealt with by the Lab/Procedure Module at some point. Setting colors/filters for abnormal readings should be straightforward to add to the procedure module. A lab module addition is about ready to be committed to sourceforge which sends collects lab results and sends to the providers to sign out: http://sourceforge.net/tracker/?func=detail&aid=3188407&group_id=60081&atid=1245239
Please place your useful feature request in the tracker.