[vvcemr] Diagnoses, Problems and Procedures

  • From: Simon Roe <Simon_Roe@xxxxxxxx>
  • To: vvcemr@xxxxxxxxxxxxx
  • Date: Thu, 2 Oct 2014 09:00:19 -0400

It appears that, as in UVIS, it will be difficult to find the meaningful
Procedures for a patient in VetView. It will be very easy to list
everything that is categorized as a procedure and has a procedure code, but
these are of limited help when a clinician is trying to understand the
previous management of a case. An example would be Exploratory Laparotomy.
This will be a procedure, but doesn't tell the clinician what was done. It
might lead to a diagnosis of Liver Carcinoma, but was it
removed/biopsied/?? There is a need for greater clarity, just as we have in
the Problem/Diagnosis process. We need a Major Procedures list. Currently,
on paper, I enter the major procedures in the Master Problem List. So,
after a problem of hip dysplasia, I will add "Total Hip Replacement, BFX,
Left". If the dog is later lame on the right hind limb, it could still be
hip dysplasia. If he is lame on the left hind limb, the differential
diagnosis list is quite different.

While it is possible to continue this approach in an EMR, it muddies the
MPL and makes an entry that doesn't fit the SOAP process. It would be
better to have a separate list. My thoughts are that it would be very like
the Diagnosis process where there would be a major term, the ability to add
qualifiers, and a free text comment if needed.

I would love to hear thoughts from others about this concept, and other
suggestions for how this could be done

Simon Roe

Dr. Simon Roe, BVSc, PhD, Diplomate ACVS
Professor, Small Animal Orthopaedic Surgery
Randall B Terry Companion Animal Veterinary Medical Center
1052 William Moore Drive,
Raleigh, NC 27607

Ph: 919-513-6334 office  919-513-6588 clinic

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