Inpatient EHR Overview - hmislk/hmis GitHub Wiki

Inpatient EHR — Overview

The Inpatient Electronic Health Record (EHR) is the clinical documentation layer of the BHT. It stores all clinical information recorded during the admission — allergies, assessments, ward medications, discharge medications, clinical discharge, and supporting clinical data such as investigations, images, and the diagnosis card.

All EHR data is linked to a single BHT (PatientEncounter). Access is from the Admission Profile Dashboard → Clinical Data panel.

Controller: InpatientClinicalDataController (@SessionScoped)

EHR Sections

Section What it stores Article
Allergies Drug/substance allergies recorded for the patient Inpatient EHR — Allergies
Clinical Assessment & Notes Doctor notes, ward rounds, clinical observations Inpatient EHR — Clinical Assessment and Notes
Ward Medications Inpatient prescriptions during the stay, the Medicine Timeline, and Request Selected from Pharmacy Inpatient EHR — Ward Medications
Discharge Medications Take-home prescriptions at discharge, with Create Discharge Issue Bill Inpatient EHR — Discharge Medications
Clinical Discharge Doctor's decision to clinically discharge the patient Inpatient EHR — Clinical Discharge
Investigations Lab results and investigation items linked to the BHT Inpatient EHR — Clinical Data
Images Clinical photographs and radiology images Inpatient EHR — Clinical Data
Diagnosis Card Structured diagnosis summary, printable Inpatient EHR — Clinical Data

Data Model

EHR data is stored as ClinicalFindingValue records. Each record carries:

  • clinicalFindingValueType — the type of finding (e.g., PatientAllergy, WardMedicine, DischargeMedicine, EncounterDiagnosis)
  • patientEncounter — the BHT this record belongs to
  • patient — the patient
  • itemValue — the drug or item (linked to the Item entity, which participates in the VTM/VMP/AMP hierarchy for medications)
  • prescription — for medication records: dose, frequency, duration, route, indoor/outdoor flag
  • stringValue — free-text notes associated with the finding
  • lobValue — long text (for clinical notes, diagnosis narrative)
  • createdAt / createdBy — audit fields

Allergy Checking at Prescribing

When a prescriber adds a ward medication or discharge medication, the system checks the new drug against the patient's recorded allergies at the VTM (Virtual Therapeutic Moiety) level:

  • If the drug's VTM matches any recorded allergen VTM → a yellow ALLERGY ALERT growl message is shown
  • The prescriber can still proceed, but the alert is visible and logged

This is implemented in InpatientClinicalDataController.getAllergyWarning() and fires from addAdmissionWardMedicine(), addEncounterMedicine(), and addPatientMedicine().

See GitHub Issue #20831 for implementation details and Issue #20832 for the planned ATC/VMP/AMP hierarchy upgrade.

Features Not Yet Implemented

The following capabilities are on the roadmap but not yet available in the current codebase:

  • Drug-drug interaction (DDI) checking engine
  • Allergy auto-check at ATC / VMP / AMP hierarchy level (Issue #20832)
  • Structured nursing care-plan template library
  • Discharge TAT monitoring dashboard

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