Composition Choice for recording a recommendation/management list

Clinical
1

We are looking to record a simple management/recommendation list at the completion of a clinical encounter using the recommendation archetype. This would be a simply list, initially without actions and will not be a persistent record.
We were wondering what composition to store this in? We were considering either the Encounter or the Progress Note composition.
What are peoples thoughts on this?

2 Likes
2

Hi Andrew,

Welcome!

I would use either, depending on the clinical context. Progress notes are more related to ongoing care notes in an institution, probably. While encounter suits more a visiting consult in an institution or a GP visit or similar.

Cheers

Heather

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Hi Heather
Thankyou so much for getting back to me with this it is really helpful. I think in our situation an encounter will be more appropriate.

I was wondering if you wouldnt mind giving me a second opinion on something. So in this same scenario where we want to record a clinician “Management Plan” just in list form, for example

The management plan would be:

  1. Follow up in face to face clinic in 4 weeks for laser treatment
  2. Start Lucentis injections
  3. Follow up with GP for diabetic control

Do you think the recommendation archetype is the best? I was recently looking the “service request” archetype as well and wondering if this would be more appropriate?

Many thanks again
Andrew

4

Hi Andrew,

I agree. The Recommendation archetype is intended to capture proposed management as a narrative. If I remember correctly, the original use case was the need for a recommendation within second opinion consult, or similar, situation such that the patient’s usual clinician could then choose what orders etc would be made as a further, intentional step.

That sounds like it matches your scenario well. However, remember this archetype is just for the purpose of recording.

On the other hand, the Service request is used to represent an order/instruction. It is a good alternative and, if used, would usually be implemented with a matching ACTION that would start in the ‘Planned’ state. However, this is a more complex implementation and requires that it be resolved by being made active or cancelled etc in future.

Regards

Heather

5

Hi Heather,
Yes spot on with the use case. Basically we are looking to be able to record a list of “outcome/management” instructions but without performing any of the actions that one might want to as part of management. Ideally we want to make it flexible enough to be able to capture different different outcomes depending on the situation. I think Recommendation will be the one to go with.
Thankyou so much for your advice on this I really appreciate it.
Andrew

6

Hi Heather,

The Encounter composition with Recommendation archetype is what we’re going to use.

We did have another question regarding the best way to structure the template.

For our use cases, we often need both external coded lists and free text to be recorded in the “Recommendation” node of the archetype.
As far as we can tell, you can’t have both an external coded list and plain text at the same time.

We’ve thought of two ways around this:

  1. Have two Recommendation archetypes in the composition, one for the coded text, one for the free text.
  2. Have one Recommendation archetype, but edit/specialise the archetype to have 2 “Recommendation” nodes.

Are we on the right track and would either of the approaches be preferrable?

Thanks in advance!
Kieran

7

Hi Kieran, it would be helpful to have some examples of what would comprise the coded list and free text.

EVALUATION.clinical_synopsis is one designed as free text and used for narrative descriptions of a summary or conclusions of an event or episode of care.
Recommendations is intended for advice re future management.

Perhaps use the Recommendations for the coded values and the Synopsis might cover your narrative requirements , including justification for the recommendations?

Does that work for you?

Regards

Heather

8

Thanks Heather.

An example would be like what Andrew had above.
Again this would just be recording the management recommendations, rather than actually implementing the actions.

In the example above, the coded list options could be:

  • Continue home monitoring
  • Follow up in face to face clinic
  • Follow up in virtual clinic
  • Follow up with GP
  • Discharge from pathway
  • Admit to hospital

Whereas the free text section could record anything extra or more specific that the clinician wishes to recommend. e.g.

Consider starting Lucentis injections
Aim 5kg weight loss
etc