2013-09-22
Physician-patient encounter for HMIS & eHealth
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| A physician performs a routine checkup on a patient at the medical clinic. (Photo credit: Wikipedia) |
Initially there will be a rapport building phase for new patients which naturally will be unstructured. This is followed by history taking and clinical examination. A physician may take notes during this process, but the information on his notes generally will be semi-structured. This information is transcribed into the EMR in a fully structured form though free form text may be needed to capture certain elements.
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The basic steps in a physician-patient encounter
The physician arrives at a list of probable diagnosis (differentials) following which the physician may go back to history taking and examination to find more clues for a definitive diagnosis. Clinical decision support systems (CDSS) may be useful during this phase. Physician requests investigations and comes to a more specific diagnosis.
Management starts with a specific diagnosis in most cases. CDSS helps during this phase along with computerized physician order entry (CPOE) and ePrescription. When the patient comes for follow-up, these steps are repeated and the initial diagnosis is re-evaluated.
Labels: Clinical decision support system, eHealth, Electronic medical record, EMR, Healthcare, Patient, Physician
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