Working with Progress Notes
Progress notes follow the general concept of SOAP notes as first proposed by L.L.Weed back in the 70ties.
Reviewing Progress Notes
Different objectives require a different mindset in looking at a situation. The GNUmed progress notes viewers support just that. Currently there are two of them.
The EMR Journal
German EMR users (and others I am sure) will recognize this way of looking at patient data. It chronologically lists clinical data based on when it happened (in nearly all cases this will be when it was entered into GNUmed). Within one date the data is ordered by its SOAP category. Here are some things users need to be aware of:
- structural elements (encounters, health issues, episodes) are displayed but not taken into account for ordering
- some clinical data (such as lab data) is stored in the backend in structured form instead of as plain text
- this means it is not shown in it's full glory in the journal
- rather the relevant data (say, test name, result value and normal range) is extracted from the database
- nevertheless the full detail is still available for display with another viewer
This viewer is read-only.
The EMR tree browser
This viewer displays clinical data in a tree-like view. The EMR structure forms the trunk and branches while the actual progress notes form the leaves. The left hand side displays the tree structure:
EMR of patient ...
- health issue 1
- episode 1
- episode 2
- encounter 1
- ...
- encounter n
- ...
- episode n
- health issue 2
- ....
- health issue n
Single left clicking a tree item causes display of details associated with that item on the right hand pane. Selecting an encounter item will display the progress notes associated with it on the right hand side. They will be selective to the episode the encounter is listed under. Note that one and the same encounter can be listed under several episodes -- namely when the patient attended the clinic with several problems at once.
There is a dummy health issue displayed which groups together all the episodes that are not attached to any existing health issue (yet ?). Right-clicking on a tree item pops up a context menu for it allowing to re-group the EMR items.
Entering a Progress Note
To enter a note you have to follow these steps:
- activate a patient with the patient search box in the top panel
- raise the progress notes tab
- type your note
- save it into the EMR
- somewhere along the way you'll have to decide which episode the note belongs to
If you already know which episode the progress note belongs to you can double-click the relevant episode in the problem list. You will then be given a pre-associated progress note editor to type into. Both notebook tab and first line of editor will show the episode description. If the problem you clicked on happened to be a health issue you will be asked to select or add an episode for that issue.
If you do not yet know the associated episode - which often happens with new patients or new problems in old patients - you can use the pre-opened unassociated progress note editor or open yourself a new one with the appropriate button. Once you realize a good name for the new episode you can type it into the first line of the editor which will suggest episode descriptions from the existing ones or allow you to start a new one. If you haven't typed a name for the new episode but have pressed [save] you will be asked to provide an episode name.
Pressing [save] will save the progress note into the EMR of the currently active patient and close the related progress note editor.