Tuesday, January 26, 2016

A 65 years old woman with backache, knee pain & abdominal problems since 1 year (UDHC data capture and representation hands on training module)

This is a UDHC data capture and representation hands on training module where we are trying to guide the creation of an online-patient record. This is done after obtaining informed consent from the patient and de-identifying the patient as per HIPAA guidelines. 

On the list of patient identifiers to be removed before they can be shared online, here in figure 1, there are 19 identifiers that we must make sure are absent in our online record of the patient. 

Every record begins with this paragraph: 

"This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctor's notes and patient's voice, posted here early winter 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive for a discussion initiated by patient's primary care physician in-charge: 

This is followed by the history: 

Following is a sample history that is being guided hands on here

C/O: backache,
           knee pain & abdominal problems
           Dufficulty in walking time & rt. knee pain

All those problem since last 1 year. (C/O complains of?)

HOPI: (History of present illness?)
chief complain: back pain and difficulty in normal walking with inability strait posture (shuffling gait) last 1 year
present/c: both knee pain with swelled rt knee last 1 month , 

Instead of writing it this way we would prefer the history to begin with the patient's story in detail: see this past samples here,

Followed by a structured questioning using this template (mainly see page number 9-14):

After the histories we have to make it a point to capture the clinical images. 
Just take an image of the area where the person has the problem and then if necessary you can even add an arrow in that area in the image to indicate the exact site of the problem. See past sample here

Below the clinical-images please upload the images of the radiological investigations only (and type out the other investigations).
See past sample here

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