Unverified Problem and Medication List

Discussion in 'Synapse' started by Jerry, Apr 15, 2010.

  1. Jerry

    Jerry Administrator Staff Member

    When a patient reports a problem or diagnosis on the patient history form at intake, I discuss it with them, but maybe 50% of the time may still not be sure of the exact historical diagnosis. Same is true for prior medications. I wonder if it would be possible to have "Historical Problem" and "Historical Medication" lists where these are just simply entered sort of "free form" and quickly visible or accessible. If I have to enter a start/stop date, exact ICD9 or ICD10 code and maybe some details about each diagnosis to enter it for a patient, this is prohibitive, and 90% of the time I probably won't do it unless I'm pretty sure. I"ll just enter the diagnoses that are important for today. Sure, it's possible to put these things in a consult note tagged "Prior Diagnoses and Medications" or something, but a free-form list that could be printed to any consult note (or not) just like the "formal" diagnoses and medications would be more ideal.
  2. Graham

    Graham Developer Staff Member

    I guess I'm against having separate lists as it just makes one more place to have to track similar data.

    When entering a diagnosis, you do not need to enter a ICD code, or age of onset. What I do if I am unsure about the diagnosis is to add a "?" at the end to show this. I can also edit the details panel but that takes more time. I can also prefix the diagnosis with a "*" so that it shows on the diagnoses list, but does not print. The "*" trick is used to hide sensitive diagnoses.

    Tracking old medications is just switching to the old meds tab and entering them there. No need to put doses etc, or codes.
  3. Graham

    Graham Developer Staff Member

    This is bad .. but the obstetric applet visits/meds & concerns has a section for free text entry of diagnoses and medications.

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