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Requirements: Patient Notes

Joel Worrall edited this page Feb 17, 2016 · 1 revision

Background

In all the clinical interviews we've conducted, the Notes function in an EMR ranks as one of the top 2-3 features both clinically needed and most frustrating for clinicians.

  • clinicians need to be able to see the history of the patient with the notes inline, ordered by date but also contextually associated with visits, procedures, labs, pharmacy, etc.
  • clinicians need to clearly see who offered the note.
  • clinicians want it to be straightforward to add/edit a note, regardless of where they are in a patient record.

Data Model

Thus, notes are a list that is associated to a patient, yet they can have have nested associations to:

  • Patient History
  • Social Work
  • Visits
  • Procedures
  • Labs
  • Imaging
  • Pharmacy
  • Other / General

An ideal interface would present the patient history as a series of chronologically-ordered notes, with the various objects both embedded (and clickable) in the history.

For instance, for each visit, the history of the visit would be clearly visible through the Notes.

More....