The Concepts used in the GNUmed EMR

Synopsis

If you know what this is all about you can stop reading here.

What it All Means

The Encounter

An encounter is a once-off contact of a patient with the health care system. In a GP setting most encounters start when the patient enters the practice. It ends when the patient leaves the practice. Contact with a doctor may or may not have taken place. An encounter need not end on the day it started, eg when care is given over midnight the encounter will span a date boundary. Likewise there may well be two or even three encounters in one day (think of patients you see in the practice in the morning, send home but have to admit to hospital in the late evening).

Problem-Oriented Documentation of Care

This means that all recorded clinical data is associated with an explicitely stated problem a patient is suffering from. Problems need not be diagnoses. They need not be hard scientific facts. They can be syndromes, they can be findings, they can be history items. Over time they are likely to merge and consolidate into well-founded diagnoses. Or they may not. That is the beauty of GP level care.

Note tha during one single encounter several problems with the patient's health can be dealt with.

The SOAP Schema

In 1964 Lawrence L Weed introduced the SOAP structuring of progress notes in medical records. This concept roughly says that all clinical data associated with giving care to a patient is to be grouped into the categories Subjective, Objective, Assessment, and Plan. Various criticisms have been put forth as to where this classification lacks sophistication or falls short of properly capturing clinical information. However, shunning academically proper validation and evaluation most clinlcal data at the GP level can be grouped into one of:

Each problem will have it's own dedicated SOAP-structured data.

The Episode of Care

In the course of possibly several encounters a few health problems will be worked on. The time from the first until the last encounter for a given problem is the corresponding episode of care. It is entirely at the discretion of the clinician how long the episode lasts. Usually an episode will only be recognized as "case closed" when the patient does not report back for an extended period of time.

Each episode of care may comprise one or several encounters. An episode may be associated with a health issue.

The Health Issue

At times the clinician will recognize a clustering of distinct episodes of care looking suspiciously related. In such cases it may make sense to group them under one health issue. Thusly, health issues are fundamental issues with a patient's health. They may be active or inactive. Post-MI state is likely to be clinically relevant for the rest of the patient's life. It may not be an active problem at a given time, however. OTOH a traumatically amputated finger will always be a clinically relevant and active problem. Health issues are much more likely to be diagnoses than problems are. In GNUmed health issues are equivalent to past medical history items.

Each health issue consists of one or several episodes of care.

The Problem List

The problem list (the list of active problems) consists of items being worked on or kept in mind when trying to improve the health of the patient. This list includes the clinically relevant health issues and the open episodes. Health issues marked as clinically not relevant are not included. Neither are closed episodes.

Putting Things Together

The structure of a patient's EMR can be seen as a tree:

* health issues aggregate clinically related episodes of care

-- KarstenHilbert - 16 Jun 2005