SynapseDirect

I have been thinking about this for a while.

I'm not sure any "Box Model" method will work here.  Flexibility I think is ultra important.  Two patients with the same diagnoses may require vastly different disease "summaries".

Keeping a list like this up to date, will prove a challenge.

My actual suggestion was .... a tab called PMHx  (Past Medical History).

Where the diagnoses Tab is more of a diagnostic tag for the patient's chart ... the PMHx can go into detail, when the clinician feels it important (every doctor has their own things they feel are important).

I was going to make it easy on you and suggest that the PMHx could be identical to the SHx tab ... (maybe with versioning).  Free Form reigns supreme. 

One use for consultants would be that opening "Summary Paragraph" that many consultants start their notes with.  The best example is Cardiologists.  To me, it's like they are reminding themselves, but to new doctors involved in their patient's care ... it's a quickie helpful summary.

One cardiologist ... does this..

Re:   Lastname, Firstname

DOB: Jan 1, 1930

Dear Dr. Referring:

Firstname Lastname was seen in my office on DATE.

As you know, [insert PMHx summary] 

ie. He is a 76 year old man with bypass surgery in 1990, circumflex graft stenting in 2001, and hypertension.

(that is a short one, some patients have longer ones).

For me, I'd use the PMHx mostly for free form notes on MAJOR diagnoses.  It would be a place where Two to three sentence summaries on major patient issues would be discussed.  This section would slowly grow over years. 

If the truth be known, I've been using the Social Tab for this for selected patients.     I often find myself copying and pasting summaries from consultants into this section.  Our local Cancer facilities often have a 2-5 line summary of the cancer care for patients when sending referral notes.  I just cut and paste this info into the SHx section so I can access it later.

Many other doctors might have other uses for the PMHx tab.  It is really handy to have a "Free Form" Medical Notes section.  EMRs often have too rigid structure and the details of the patient's care get lost in codified mumble jumble.  Viewing a patient as a set of ICD9 codes was pushed on doctors via silly billing requirements.