How to Keep the EMR Nicely Structured
Adding Clinical Data
In the progress notes editor one can select the episode under which a SOAP note is to be saved. This can be done by selecting a problem from the problem list. If the problem is a health issue (eg. past medical history item) a new episode is created for that health issue. If the selected problem is an existing episode the data will be saved under that episode. One can also opt to create an entirely new episode that is not attached to any health issue as of the time being. New health issues (in other words past medical history items) can be added from any progress note editor by typing the keyword "phx" and filling in the popup dialog. The keyword may be different if your GNUmed installation is set up for another country.
Encounters are generated automatically by the system.
Regrouping of, Editing, and Deleting Clinical Data
Health issues and episodes can be edited, deleted and regrouped from the tree view of the EMR. Right-click on a tree item to pop up a context menu.
SOAP data
can not be edited or moved to another encounter. It can only be amended by adding to it. It can, however, be attached to an episode different from the original one. It may be beneficial to use a closed-by-default, dedicated episode "deprecated clinical entries" to which "corrected" clinical data can be attached if desired.
Encounters cannot be edited, moved, or deleted.
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KarstenHilbert - 18 Jun 2005
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