Progress Note Examples

New patient provides a complaint and past history, exits, and returns

Mr. R comes to the clinician for a first consultation, _system_ generates an Encounter.

Clinician asks the reasson for the visit, Mr R says he has Hypertension.

Clinician opens a "Health Issue" with Hypertension as the name, brings up a SOAP via the "Progress Notes" tab in the bottom of the GNUmed screen, and takes past and family history, when he discovers that patient has Aortic Aneurism.

Clinician opens a new "Health Issue" with Aortic Aneurism as the name, where he opens a SOAP via "Progress Notes" and includes the time of onset and current treatment regimens - and goes back to Hypertension Health Issue (there is no need to save if he will continue to work with the same patient, GNUmed supports working with multiple Progress Notes of the same patient at the same time). Continues the interview, registers current medications (in the "Current Medication" field of the "Patient" tab on the uppermost part of GNUmed), conducts a physical exam, counseling and medication adjustment etc... and ends the consult by _SAVING_.

As Mr R is leaving he says to clinician "Doc, I´ll be honest, I do smoke, but I can´t let my wife know."

Clinician opens a new Health Issue puts Smoking Status in the name and starts a SOAP via "Progress Notes" where he takes the history of the smoking use, time, how much, in what instances, the will to quit; if so, medication prescribed, etc... _SAVES_ and it is included (added automatically) under the most recent encounter.

Patient leaves, Clinician opens new patient Mrs J. ... when Mrs J. exists, Mr R. (who was waiting outside the office) asks if he can talk just one more minute, "because all this morning I have been having chest pain".

Clinician opens the patient again and now, because some time has now passed, the _system_ asks if it should generate a NEW Encounter or continue the last one. The configuration of the time interval since last modifying the patient record, before which new activity will extend the last Encounter, and after which a new encounter will be created, and between which the clinician is asked, is managed via - Menu "GNUmed" -> "Options" -> "EMR" -> "Encounter" [minimum duration and maximum duration].

If clinician indicates a NEW Encounter, the _system_ will generate one.

Clinician opens a NEW "Progress Note" without yet knowing under which Episode to store the new SOAP. Further details are gathered, and are entered about this chest pain and any new examination is recorded. The patient is ordered to the emergency department of local hospital. As part of the clinician _SAVING_ the Progress note, the _system_ asks under which Episode this note is to be saved. The clinician prefers a new Episode named "chest pain" without yet associating it under a Health Issue (leaving it "unattributed") if he would prefer to wait for the hospital assessment to better define attributability to Hypertension, Aortic Aneurism, or any other thing. This adjustment can be done in a later GNUmed session after the information has become available e.g. in a future chart review encounter or a patient visit.

Clinician then calls in the next patient...

One problem spawns another... how to handle?

Thanks to Sebastian for this question in the mail archive, which received two different answers as how it could be handled. The "best" answer may simply depend on what makes the most sense for how the clinician (or the clinician group) wishes to work.
Topic revision: 25 Jun 2011, KarstenHilbert
 
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