Adding documents to the GNUmed archive

To add a document to the archive go to the "Import Document" tab of the main notebook. You will then have to follow a few steps to store a new document in the archive:

Acquiring pages

The top left column of buttons allows you to acquire objects (pages) from different sources to be added to the document. Each data source can be used as often as needed in any order.

Clicking [scan image(s)] will bring up the standard image scanning dialog for your operating system (Linux: SANE, Windows: TWAIN). It will allow scanning of one or several pages to be added to the new document.

Selecting [pick file(s)] shows a dialog which allows you to select one or several files from the filesystem to be added as pages. This includes letters written with a Wordprocessor, a PDF downloaded from a website, images from a digital camera, fax messages saved by a fax modem, audio recordings of, say, heart sounds, life ultrasound images, or any other file of any format.

The acquired pages end up in the list on the top right panel. A document can have any number of pages and the format of the pages can be mixed freely. The practical size limit is currently 1 GB per page due to database constraints.

Providing information about the document

The top middle column shows a few fields for entering information about the document. Some fields are mandatory, others are optional. The tooltip for each field will indicate whether it is required for saving the document and also provide additional hints on selecting meaningful information. Some fields have a default value.

Associated Episode

Status required
Type phrasewheel?
Policy selection or free text entry

Type in the episode to which this document belongs. Entering "*" will bring up the list of episodes existing for this patient. Note that this list shows all episodes including open and closed ones such that a document can be added to a previously closed episode. Closed episodes will be marked as such. While typing a list of episodes matching the already typed fragment will be shown for selection. If none of the existing episodes is selected a new one will be created and named with the text that was entered. It will not be associated with any health issue yet.

Not all documents will pertain to a single episode only (think discharge letters in multimorbidity patients). In such cases select the main episode (main diagnosis ?) - perhaps the one that led to the admission in the first place. The database allows to associate any number of additional episodes with a document but the user interface does not yet support setting them.

Type

Status required
Type pick list
Policy selection only

Select the type of the document. Note that this pertains to the type of content of the document, the clinical type, that is. It does not refer to the "file format" or mime type (the technical typ). Think of "discharge letter" rather than "PDF file".

GNUmed comes pre-configured with a range of types suitable for most documents occurring in a GP practice. Note that your system administrator can safely add as many document types as needed for your site.

Comment

Status optional
Type text field
Policy free text

Enter a short comment concisely describing this document. A good comment does two things: It further identifies the document over and above its type and hints at the essence of the content: (such as "annual check: no changes" for an echocardiography or "St. Johns Ward 3 Dr. House: TEP left hip"). This comment will later be shown in the document tree to aid in identifying documents relevant under given circumstances.

Date of Creation

Status required
Type timestamp
Policy valid timestamp

Enter the date of creation of the document content Into this field. It defines at which point in time the information was considered clinically valid. This field will later be used to order documents by relative age. Sometimes a partial date such as "8/99" will have to suffice. Do not create artificial accuracy.

The default for this field is the current date.

Intended Reviewer

Status required
Type phrasewheel
Policy selection only

Here you can set the staff member that is to be notified about the new document in order to review it and initiate proper clinical action. In most cases this should be the primary doctor for the patient. The default is the currently logged in staff member.

Deciding on the Review Status

The lower part of the middle column provides fields to allow immediately attaching a review to the new document. This review will always be attributed to the currently logged in staff member (you, that is) regardless of the setting of Intended Reviewer ! Of course, both may be one and the same person.

Sign off

This setting decides whether a review will be attached to the new document. Checking the box will enable the two checkboxes below it. Unchecking it will disable them.

Technically abnormal

Check this if the document contains medical information that is outside the normal reference range or not a "no abnormalities detected" (NAD) result. Note that it does not matter whether the technical abnormality is clinically relevant or not.

Clinically relevant

Check this to indicate whether this result is of clinical relevance. Note that clinical relevance does not require technical abnormality. Results well within normal reference ranges can surely be of importance, eg. when a range does not apply to a given patient or normal results are abnormal for said patient.

Saving the new Document

The [Save] button is at the very bottom of the window. If some required fields are lacking proper data messages will be displayed to that effect and saving the document will not occur. A successful save will be signalled in the statusline of the client without interrupting the workflow. A unique identifier for the document is created and displayed. You should note down this identifier on the physical document for indexing later on.This identifier is a convenient link between your physical and digital document . In case you have no need for such identifiers because you throw away the original paper documents anyway (or you only ever import files) you may turn off the display of the identifier in the GNUmed configuration.

Eventually the window will be initialized ready to accept data about the next document to be added to the patient's EMR.

Hitting [Discard] will allow you to start over without saving anything to the EMR.