Re: [Health] Confusions in Patient Evaluations Main Info

[Luis Falcon]

Dear Khurram

On Mon, 25 Apr 2016 14:52:21 +0500
Khurram Shahzad <address@hidden> wrote:

> Dear All,
> 
> We had the first demonstration of GNU Health to the doctors of
> hospital today.
> 
> I could not convince doctors for the usage of any section of "Main
> Info" tab except the the "Hypotheses / DDx" section.

You are talking about the Patient Evaluation / Encounter, right ?

> 
> Can anybody explain me the use of all the sections in the "Main Info"
> tab of patient evaluations with some real world case? If you can
> share some pointer to some details regarding these sections, that is
> also appreciated.

The main info section summarizes the patient encounter flow and shows
most relevant information and procedures :

* Chief Complaint
* History of Present Illness (HPI)
* Clinical / Physical exam summary (check also the clinical tab)
* Main Condition (Presumptive Dx)
* Other conditions ( See ICD10 coding guidelines if you use this
  standard)
* Differential Diagnoses (DDx)
* Procedures (ie, Systemic arterial pressure monitoring)
* Treatment plan

You might want to also look at SOAP, but I'm positive the Heath
professionals are familiar with this concept. It might also help to
see a working example on the community database.

Depending on the type of evaluation, different fields might take more
relevance.
 
+> 
> The doctors also say that there is no need of "Procedures" section in
> the "Main Info" specially for OPD patients. Any ideas?

It reflects the procedures done, both in Outpatient and Inpatient
settings. Although is not required, it's good practice to record them.
Take the example of "Systemic arterial pressure monitoring" (ICD9
89.61).

But of course, each institution, can customize, and is not a required
field.

All the best

-- 
Dr. Luis Falcon, M.D., BSc
President, GNU Solidario
GNU Health: Freedom and Equity in Healthcare
http://health.gnu.org