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Encounter, Episode, Health issue, Problem

Encounter = interaction with the patient (record), involving the patient directly or indirectly. Encounter, then, is a self contained relationship with patient (i.e. it starts and ends). Examples: in-person visit; phone call; review of chart / results. There can be more than one reason, sometimes known only after the fact, for why this encounter was necessary, its purpose(s) or in other words the "Reason for Encounter" (RFE). There is also the possibility in GNUmed to decide and store some overall assessment of this encounter, the "Assessment of Encounter" (AOE) as further elaborated on GmManualBasicProgressNotes.

Episode = for any problem(s) or issue(s), a set of one or more encounters where the "last-in-set" denotes a definite or apparent or expected natural ending. Examples: death; resolution of symptoms / findings. Episodes remain "open", i.e. without a designated "end", until the clinician decides to mark them "closed", which may happen only when the patient returns for an unrelated reason and confirms whether the other has in the meantime subsided.

Health issue: one or more clinically-related episodes of care, aggregated under a clinically-suitable grouping name (diabetes, hypertension, chronic kidney disease, lupus). Note that among a patient's episodes, some will involve an as-yet undiagnosed set of complaints, which can often be self-limited and so not all episodes will get aggregated under a health issue.

Problem: open (active) episodes, and any health issues that, even if "inactive" (no open episodes), are of potential importance

encount"let" = the { S | O | A | P } portion(s) of a multi-issue encounter that pertains to a particular problem or a particular health issue. In the case of a single-issue encounter, the encountlet is the encounter.

How this works

Referring back to the example at Dipity, we recall that encounters would be chronological along the time line, with each encounter contributing to one or multiple episodes.

Now, if you go straight up from one particular encounter you will cut through a few stripes == episodes. If you want to print the encounter details within the entry for each episode (as we do in the EMR tree) you will see the same encounter printed several times. And if you edit the encounter at the bottom it will show up changed in all the episode cross-sections.
Topic revision: 20 Jan 2013, SebastianHilbert
 
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