How do we relate the clinical notes (in one template) with the associated diagnosis (in another Template)?
After asking opinions in this forum, doing research, reading, observing models in CKM’s, we have decided on THIS solution to model our use case.
We record, in the CLINICAL NOTES TEMPLATE, the associated diagnosis, with a DIFFERENT ARCHETYPE, custom CLUSTER, allocated in the context.
The information of the diagnosis in that custom_Cluster_diagnosis will contain: name of the problem and the terminology code, and will work as a reference.
The Problem/diagnosis information will be allocated in these other Template
CONTEXT:
Let’s say we are modelling a Clinical Workstation. This station would cover the need for a primary care consultation. A longitudinal record for primary care. The healthcare professional has an assigned population group. She/he regularly visits his/her patients, gets to know them and manages their health problems throughout their lives. She/he jots down notes of his/her performances at each visit in clinical notes. Associated with these clinical notes, the healthcare professional manages, medication, diagnosis record and makes requests if necessary.
To manage the construction of this clinical workstation, it is divided into smaller project. These results in a project that models requests, another project models the diagnosis record and another the clinical notes.
This generates, a Template for each of these functionalities or modules. A Template for the clinical notes, a Template for the list of the patient’s diagnoses throughout their life, and so on.
Our job is the modelling of the clinical notes.
The clinical notes contain FREE TEXT, not structured, that gives context to the structured information gathered during the visit of a GP.
One clinical note is associated with one or more diagnoses .
Every time a patient consults a GP in a Primary care visit, a clinical note is generated. This clinical note can be associated to one or several diagnosis ( The GP selects one or several diagnosis from the available diagnosis of the patient). If there is no existing diagnosis that matches the problem, the GP creates a new Diagnosis for the patient (Template encounter Diagnosis)****, so that there is an available diagnosis to select and to associate with the clinical note.
Therefore, the problem / diagnosis is already persisted in the CDR (with ALL the information required).
SUMMARISING with different words, this is the model chosen to solve our use case:
-------Template Diagnosis -----------------------------------------------Template Clinical Notes—
