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A new medical record item - Summary

Submitted by Guest on Tue, 12/04/2016 - 19:05
in

The following note came in from the Practice Manager in Hong Kong:

"We had a vet meeting the other day and the vets were wondering if it's possible to increase the character limit in the patient visit summary to around 500 characters? It's currently set at 50. The idea is that we wanted to use that summary to have a running up to date summary of what is happening.

Eg. Renal failure, last blood test on Thursday, keep in hospital until Wednesday, no abnormalities on u/s, please repeat bloods on Friday.

Do you think that would be possible?  If not, that's cool - I just thought I'd check."

This led to an investigation of the possibilities and discussions with Tim A which have resulted in the following proposal:

A new medical record item will be created called a Summary.  It will have the same structure as the current Note, ie date, text up to 5000 characters, and clinician. However:

  • only one is allowed per visit
  • if there is a summary record, then this appears first in the visit items directly after the visit
  • the summary record is NOT subject to locking - ie it is a text area that is alway available to editing even when the rest of the visit items are locked
  • the summary is not included in the printed version of the medical record - ie the standard Medical Records template will not print the summary. This is intended to allow one to generate a 'clean' print of the medical records that does not include the Summary record - which is intended for in-house use only and 'not for publication'.  Of course, with a customised version of this report, the printed record could include the summary.
  • one will be able to change the background colour of the summary via a history.summary.colour setting in default.properties (the standard setting is white - ie '#ffffff')

You create a Summary record just like a Note - ie press the New button and select Summary. However, having created one for a visit, if you press New again, then Summary will be missing from the list of things you can create.

Although the Summary has a date and clinician field, the are essentially set when the Summary record is created - though there is nothing to prevent someone editing the summary record from changing either field. [Thus a practice might want to adopt the convention that when you edit the Summary, that you change the date to today and the clinician to yourself - ie these fields reflect the last person to add to the summary.  Again a practice can elect to adopt the convention that new stuff is added at the top or the bottom of the text.]

In the Medical records Summary display it will be possible to just select the Summary to be displayed.

======================

Comments please.  Regards, Tim G

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Re: A new medical record item - Summary

Submitted by Ben_Charlton on Wed, 13/04/2016 - 09:56.

To be honest the whole idea sounds flawed...

1. It doesnt adhere to conventions that medical records should be accountable.   

It gives vets a field that is changable and would inevitably lead to it holding data that should be stored in the patient history.  

And then the idea that if a vet edits the summary its updated to show his name and date means that prior bits are then attributed to him...so when the shit invariably hits the fan on a case you cant hold anyone accountable...

It large practices where multiple locations and vets have access I would see this as causing more arguements that being good.

Isnt this what the problem list is for...it holds summaries of ongoing issues. and holds the attributed entries to the problem in chronological order.

Am I missing something - apart from the fact it isnt immediately visible on the medical record ...but then it is called a medical record for a reason

Regards
 
Ben 
OpenVPMS Installer and Helper 
Ph: +61423044823 
Email: info[at]charltonit.com[dot]au

Re: A new medical record item - Summary

Submitted by Ben_Charlton on Wed, 13/04/2016 - 10:18.

It sounds like you almost want a new entry stored on the patient file (not in the medical record) that stores a current summary. ie you only have 1 per patient not even 1 per visit.

Regards
 
Ben 
OpenVPMS Installer and Helper 
Ph: +61423044823 
Email: info[at]charltonit.com[dot]au

Re: A new medical record item - Summary

Submitted by EastsideVetEmerg on Wed, 13/04/2016 - 12:44.

Hi,

 
Ok, I will preface this by saying that my preference is for simplicity and not adding more options unless absolutely required.
 
If my staff asked me for this my reply would be that this is exactly what a SOAP style medical record is for (what you are talking about is essentially an editable field for ASSESSMENT and PLAN). However this should (in our world) be updated as each vet looks at the patient. For us this is every 12 hours at a minimum. It should be locked (otherwise what stops people going back and changing what they said was the assessment/plan?)
 
My feelings about this is that:
- Such a 5000 character field will be used in place of a medical note and thus open to abuse and a workaround to the entire point of medical record locking. People will use it to write notes and avoid medical record locking.
- How are you going to be able to work out who wrote what? Traceability and accountability goes out the window.
- This is still part of the medical history and needs to be recorded and locked.
- If it was ever adopted it would need to be selectable to turn this field on/off at a practice/practice location level. We would not want staff to have an option to use such a field.

Re: A new medical record item - Summary

Submitted by trilby on Wed, 13/04/2016 - 14:09.

Hi all,

 
I agree that we don't want to add complications, however in my practice (where we are writing 12 hourly SOAP style medical records, 7 days a week) it's often hard to get an idea of the 'big picture' without reading through 20 or more medical notes.  Pertinent aspects of the case aren't necessarily repeated every time a new record is written, and there are other aspects to a case which are not appropriate to write in the medical record on a daily basis. ("such as - owner out of town, please make sure you call the wife on her mobile phone").  In our particular case, we wanted to achieve something similar to medical rounds, where the vets discuss each case individually - however in written form, so that everyone has access to the latest summary. 
 
If this is what the 'Problem' tab should be used for, perhaps we should consider using the problem tab for this purpose and having it visible in the summary page, with functionality similar to what's been proposed for this summary. No one seems to have any issue with the fact that problems aren't included in medical histories.
 
My idea was not to change the way medical histories were written, but just to make it simpler to get an overview of the whole case. If anyone has any other suggestions on how to do this it would be most appreciated.

Re: A new medical record item - Summary

Submitted by Ben_Charlton on Thu, 14/04/2016 - 10:33.

For things such as "owner out of town" this would be most appropriate in a client note field.

As you have a read above ...I dont think you will get any traction from anybody if you want a unlockable summary anywhere near the medical record.

I can think of two places that a summary might be appropriate -

First is on a Problem entry - add a summary node to this archetype and have it displayed in the medical record this would mean for each admssion you would require your staff to select a Presenting Complaint and Diagnosis.  Optionally they could record a summary of the problem.  It would still be lockable but might only lock once a problem is considered resolved OR 1 mth has passed.

Finally the other place as I mentioned before would be a field directly linked to the pet.  This field would hold a summary of the patient across its entire history at the client and would effectively be equivalent to a patient Note.

 

Regards
 
Ben 
OpenVPMS Installer and Helper 
Ph: +61423044823 
Email: info[at]charltonit.com[dot]au

Re: A new medical record item - Summary

Submitted by alanb (not verified) on Thu, 14/04/2016 - 00:18.

I agree with what has been written before me. I will also add that I am concerned about this not being part of the patient's complete or formal record. If this is employee generated, it needs to be part of the record and follow the same locking protocols. 

Re: A new medical record item - Summary

Submitted by alanb (not verified) on Thu, 14/04/2016 - 00:18.

I agree with what has been written before me. I will also add that I am concerned about this not being part of the patient's complete or formal record. If this is employee generated, it needs to be part of the record and follow the same locking protocols. 

Re: A new medical record item - Summary

Submitted by tanderson on Thu, 14/04/2016 - 11:05.

Would either of the following work?

1. provide a Copy option that:

  • duplicates the selected Note into its Visit; and
  • sets the Clinican to the current clinician; and
  • displays the Note in an editor

This means you can copy SOAP notes, and quickly amend them.

They wouldn't display after the Visit however.

2. Provide a new SOAP record

This would have fields for Subjective, Objective, Assessment and Plan.
The Copy option above could be used to duplicate the last record.
Whilst they wouldn't always display after the Visit, you would be able to filter by SOAP records, to quickly see the latest one.

 

Re: A new medical record item - Summary

Submitted by trilby on Thu, 14/04/2016 - 12:06.

Hi Tim,

I think that would be a good compromise. 

Trilby

 

 

Re: A new medical record item - Summary

Submitted by Ben_Charlton on Thu, 14/04/2016 - 13:02.

Firstly a SOAP entry is probably a long time coming - I know a lot of clinics use it to record entries as part of a visit. I assume most of them macro it in a note.  

In fact I would argue a SOAP would be the default first entry as part of any admission or visit.

It would still be subject to record locking however so it couldnt be updated (although it could be copied) So you might still need to read through entries to get the complete picture.  I know from reading a number of ER reports we get each day that I need to read the entire report to get the real picture..

The copy idea seems sound.

 

 

Regards
 
Ben 
OpenVPMS Installer and Helper 
Ph: +61423044823 
Email: info[at]charltonit.com[dot]au

Re: A new medical record item - Summary

Submitted by EastsideVetEmerg on Thu, 14/04/2016 - 21:20.

Hi,

With regards to the copy function.

When we create a new note the things that always need to be updated (in our world at least) are CLINICIAN, DATE OF ENTRY, TIME OF ENTRY. I suspect in some practices the USER who creates the note (i.e. current user) would also need to be applied to the new, copied note.

We need to be careful that if this information is plain text within notes, then copying existing notes, while useful, may lead to confusion.

In my mind ideally to resolve this each note (and indeed some other record items such as attachments, weights, images, etc) should have these fields separately updated and attached...

I.e. Currently for each SOAP macro (indeed for most of our general entry macros) the macro starts with:

"VET: Dr ABC
TIME AND DATE OF SOAP: 14/04/16 06:41PM
PRIMARY CARE VET: XXX"

This is to ensure we know who and when it was created.

What would be good is if this sort of information that is required, but shouldn't be copied (as would be misleading) was created and displayed outside the text entry area of the note.

For example...

Then in the summary view each note should have:

This means this important "Who entered this and when information would always and automatically be updated. Copying would work a treat as none of this information would be dragged across.

My other concern is about the creation of a SOAP entry. There are many variations on SOAP medical records, many ways to format them, and many alternative (and valid) ways to write a medical record.  We use a SOAP format but have additional fields and items in our SOAP macro for different situations. So, putting a SOAP entry needs to be considered carefully as it may not reduce workload, and probably won't be suitable for everyone.

My suggestion is that a better way of doing this is to have a provision for a default macro in Notes that each clinic or even clinician/user can set as to their preference. There are more sophisticated variations that could happen on this theme if we were creative (e.g. 1st note in a visit has 1 macro, 2nd has another, default macros in notes could be tied to visit reason?, etc).

Re: A new medical record item - Summary

Submitted by EastsideVetEmerg on Thu, 05/05/2016 - 16:33.

Hi,

Just to bump this. Would people be interested still in having a copy button for notes.

Comments on how we would and generally do deal with the date/user creation info for each note, etc. I.e. Drawing this out of the actual note field but still having it visible and part of the history.

Cheers,

Adrian

Re: A new medical record item - Summary

Submitted by tanderson on Tue, 17/05/2016 - 10:38.

There's a couple of ways note copying could be supported:

1. A Copy button that creates a new Note and displays it in an editor with:

  • the text of the original note
  • the author set to the logged in user
  • the clinician set to the current clinician
  • the current/date time

The note would be saved to the current Visit.

2. Ctrl-C and Ctrl-V

  • Ctrl-C copies the note
  • Ctr-V pastes the note into the selected Visit, displaying an editor as in 1.

The user that created the note and the creation date/time can be displayed now, albeit in the same column as the note text. There is a file named IMObjectTableModelFactory.xml that can be customised to change the history display. To show the creation time and author:

<entry>
    <string>act.patientClinicalNote</string>
    <string>concat(date:format(/activityStartTime, "HH:mm"), ' - ', openvpms:get(., 'author.entity.name'),'&#10;',/details/note)</string>
</entry>

This will display a line with the time, follows by the author name, and on the next line the note.

The complete file looks like:

<handlers>
    <handler>
        <type>org.openvpms.web.workspace.patient.history.PatientHistoryTableModel</type>
        <properties>
            <entry>
                <string>expressions</string>
                <java.util.Map>
                    <entry>
                        <string>act.patientClinicalEvent</string>
                        <string>/description</string>
                    </entry>
                    <entry>
                        <string>act.patientClinicalProblem</string>
                        <string>/description</string>
                    </entry>
                    <entry>
                        <string>act.patientClinicalNote</string>
                        <string>concat(date:format(/activityStartTime, "HH:mm"), ' - ', openvpms:get(., 'author.entity.name'),'&#10;',/details/note)</string>
                    </entry>
                    <entry>
                        <string>act.patientInvestigation</string>
                        <string>concat(openvpms:get(.,'investigationType.entity.name')," - Request No: ",/id," - ",
                            /description, " [", openvpms:lookup(.,"status"), "]")
                        </string>
                    </entry>
                    <entry>
                        <string>act.patientMedication</string>
                        <string>concat(openvpms:get(.,'product.entity.name'), ' - Qty: ',/details/quantity,
                            ' Expiry: ', expr:if(boolean(/activityEndTime), date:formatDate(/activityEndTime), 'None'),
                            expr:if(boolean(/details/label),concat('&#10;',/details/label),''))
                        </string>
                    </entry>
                </java.util.Map>
            </entry>
        </properties>
    </handler>
    <handler>
        <type>org.openvpms.web.workspace.patient.problem.ProblemTableModel</type>
        <properties>
            <entry>
                <string>expressions</string>
                <java.util.Map>
                    <entry>
                        <string>act.patientClinicalProblem</string>
                        <string>/description</string>
                    </entry>
                    <entry>
                        <string>act.patientClinicalEvent</string>
                        <string>openvpms:lookup(., 'reason')</string>
                    </entry>
                    <entry>
                        <string>act.patientClinicalNote</string>
                        <string>concat(date:format(/activityStartTime, "HH:mm"), ' - ', openvpms:get(., 'author.entity.name'),'&#10;',/details/note)</string>
                    </entry>
                    <entry>
                        <string>act.patientMedication</string>
                        <string>concat(openvpms:get(.,'product.entity.name'), ' - Qty: ',/details/quantity,
                            ' Expiry: ', expr:if(boolean(/activityEndTime), date:formatDate(/activityEndTime), 'None'),
                            expr:if(boolean(/details/label),concat('&#10;',/details/label),''))
                        </string>
                    </entry>
                </java.util.Map>
            </entry>
        </properties>
    </handler>
</handlers>

It needs to be placed in <TOMCAT_HOME>/openvpms/WEB-INF/classes.

 

Re: A new medical record item - Summary

Submitted by EastsideVetEmerg on Sat, 21/05/2016 - 22:16.

Hi Tim,

I like option 1. Though might need to consider the name. People might click the button thinking it is like "Ctrl-C" when in fact it means "Duplicate & Create New Note".

With regards to the display. We will make this change when we next upgrade. We just will need to alter our Medical History templates when printing to also display this information....

Thanks,

Adrian

Re: A new medical record item - Summary

Submitted by tgething (not verified) on Wed, 27/04/2016 - 05:53.

I am now playing with snapshot 7018 which includes the medical records locking facility.  I note that the Visit record itself does not lock - and one is free to adjust the 50 character summary field.

Trilby's orginal note to me asked if this field could be increased to 500 characters.

It can't - because it uses the title field in the act record.

Initially I thought - piece of cake - add a longSummary or visitNotes or narractive field and put it in act_details.  But then I had the problem of displaying this - can't because I have no control over the display of the visit.

Hence, can I suggest the we do as follows:

1. add a notes/narrative/comments node to the visit - so when you edit the visit you get something like:

2) adjust the code so that if the narrative (or notes or comments) is non-null then it is displayed immediately under the existing Visit line, ie

 

This approach allows for a longer "summary" and does not affect the locking strategy [since one is currently allowed to edit the 50 character visit summary at any time].  All we have done is to functionally expand the size of the summary facility.

Regards, Tim G

Re: A new medical record item - Summary

Submitted by tgething (not verified) on Mon, 27/06/2016 - 05:04.

It is nearly two months since I posted the above and no comments.

Rather than 'Narrative' I would suggest 'Precis' - since this implies that it is a summary/synopsis/abstract/outline/summation is the visit.

I see this as a low impact method for extending the size of the Visit Summary field. It has zero impact if you don't use the facility and I supect that most users will not notice its presence (because they do not edit the Visit record).

It requires a) a tweak of the archetype; b) code to display the Precis on the medical records screen; c) and adjustment to the Medical Records.jrxml

I can do a) and c) but not b).

I really would like to get this into 1.9

Regards, Tim G

Re: A new medical record item - Summary

Submitted by EastsideVetEmerg on Tue, 19/07/2016 - 19:03.

Hi, ok, I changed my mind and agree with TimG's proposal.

Re: A new medical record item - Summary

Submitted by tgething (not verified) on Tue, 19/07/2016 - 19:34.

Adrian - the support for this is in 1.9 snapshot 7171. I added a 'precis' field to act.patientClinicalEvent and Tim A added the hook to enable this to be shown in the medical record.  I am still dickering with Trilby about whether she wants me to adjust the medical records print to also show the precis (or whether this remains an 'in-house' precis not sent out to referring vets).

Here is the visit

Here is the medical records:

When you get 7171 or later, yell and I will give you a hand to set this up.

Regards, Tim G

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