2013-09-22
Physician-patient encounter for HMIS & eHealth
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.
![]() |
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


Post a Comment
All comments, questions and criticisms welcome. Relevant comments with hyperlinks will be accepted. Though this form is not CommentLuv enabled, interesting and useful comments will be acknowledged with DoFollow links in the body of the post. Irrelevant comments and spam will be deleted.
Links to this post:
Create a Link
<< Home