OVERVIEW

This module is used by doctors when they are having a patient consultation. Through this module you can view information from a patient's previous visit(s), enter complaints and details from the current visit, and create lab, pharmacy, and radiology orders in response to the patient's condition.

GOALS AND NON-GOALS

Goals:

Allows the doctor to conduct a patient visit. During this visit, the doctor will be able to enter details of patient history, examination, diagnosis, and treatment.
Doctors have an up-to-date list of patients, which have been assigned to doctor(s) by the head nurse.
Doctors can receive alerts (from Pharmacy, Lab, others) to inform them of important cross-system updates.
Allows doctors to refer patients to other doctors for a follow-up OPD consultation.
Can view a patient record, showing registration information, vitals, and visit history.

Non-Goals (out-of-scope):

FUNCTIONALITY

View List of Patients Assigned to a Doctor

Name, address, ID, assigned doctor, photo

Display Patient's Registration Information

Name, address, ID, assigned doctor, photo

Display Patient Vitals

Height, weight,BMI, blood pressure, pulse, respiration rate, temperature, oxygen saturation

These vitals are measured by a nurse and inputted before the doctor's consultation in OPD.

Input Patient History

The purpose of history is to capture a high-level description of the patient's condition, as described by the patient. Because this information derives from the patient's speech/description, it is more subjective.

There are various aspects to a patient's history

Patient History
1. History of Present illness - a description of the immediate background which has led up to the patient deciding to come visit the doctor
2. General - information on prior illnesses for this patient
Family History - possible genetic or shared environmental influences on the patient's condition
Social History - factors such as smoking, alcohol, drug use, sexual behavior (e.g. sex prostitutes, homosexuality)
Medication History - drugs that patient has previously taken for treatment. Most important is the list of drugs which a patient is currently taking.
Lab History - all prior lab exams that have been conducted for the patient.
1. Most important is the outcome of the lab test (e.g. "positive" or "pending result") to help the doctor make decisions.
2. Any negative drug reactions should grab the user's attention (e.g. via alert, red text)

Examination

The purpose of examination is analyze and document the patient's health (physical, mental). The information generated is based on the doctor's knowledge, and should be as objective as possible.

Diagnosis

The purpose of diagnosis is to compile the information found during the visit (vitals, history, examination) and suggest a root cause for the health problem.

Our diagnoses will be categorized according to an existing medical classification system, such as ICD-10.

Treatment

Treatment is the set of

medicines
instructions

which are given to the patient following the diagnosis.

Past Visits

The purpose of viewing past visits is so that a doctor can look at prior patient records and inform her current decision making. We propose organizing this information via a "timeline" functionality. This will show a date which corresponds to each prior visit along a timeline. By clicking on that date, you will be taken to a read-only version of that OPD consultation, allowing you to see all doctor's notes which were written at that time. Additionally, this read-only version should surface the most important data easily; for example, if social history wasn't entered for a given visit, then that tab should be disabled/greyed out to prevent a user from wasting time clicking on a page with no information.

DEPENDENCIES

(IN) signifies that data flows "into" OPD from that module.

(OUT) signifies that data flows "out" of OPD into that module.

Screener

(IN) The screening nurse may assign a patient to a one or more specific doctors for a full OPD consultation.
(IN) The screening nurse may request a lab order for a patient. This request must appear in the OPD in order to be approved by a doctor (which doctor?).
(IN) The screening nurse may request a prescription (pharmacy order) for a patient. This request must appear in the OPD in order to be approved by a doctor (which doctor?).
(OUT) A doctor may unassign a patient from himself, returning the patient to the screener list.
(OUT) A doctor may assign a patient to other doctors, causes the patient to appear in other doctors' lists.

Pharmacy

()

Laboratory

()

DEVELOPER DESIGN

TEST DESIGN

NOTES

JIRA tag: "outpatient"/"opd"

OPEN ISSUES

Issue	Who Asked	Last Updated	Answer
Can the head nurse screen a patient to more than one doctor? Or should a patient always be assigned to exactly one doctor? What about emergency situations?	Nathan Leiby	Jul 25, 2012	??

REFERENCES

Medical Classification, Wikipedia – http://en.wikipedia.org/wiki/Medical_classification

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