[vvcemr] Re: Diagnoses, Problems and Procedures
- From: "Shirley T. Arck" <sarck@xxxxxxxxxxxxxxx>
- To: "vvcemr@xxxxxxxxxxxxx" <vvcemr@xxxxxxxxxxxxx>
- Date: Mon, 6 Oct 2014 14:10:00 +0000
I forwarded the post to Kathy Ellis from VMDB. Here is her response:
As a response to this person's post, it is possible to have Procedure list
similar to a diagnosis list using SNOMED. Currently the coders code the
surgical procedures as well as certain other procedures, such as Chemo. VMDB
has thrown around the idea of creating a procedure listing. What would be best
is for the EHR to use charge capture, automatically coding charges that are
specific enough to be coded without manually being done (example: spays,
castrations, tie-back surgery, etc.). VetStar currently does this. What we
need is a VMDB master procedure list that institutions could then tie into
their charges, surgery reports, etc.
From: vvcemr-bounce@xxxxxxxxxxxxx [mailto:vvcemr-bounce@xxxxxxxxxxxxx] On
Behalf Of Shirley T. Arck
Sent: Sunday, October 05, 2014 3:34 PM
To: vvcemr@xxxxxxxxxxxxx
Subject: [vvcemr] Re: Diagnoses, Problems and Procedures
I see a need for the separate MPL as well. It’s an important part of our
current paper medical record. I really like your idea about structuring it
similarly to the dx process. Would be nice if there could also be some way to
automate addition of some select problems to the MPL based on a particular
procedure that was done.
Shirley
Shirley Arck, PharmD, FSVHP
Administrator
Veterinary Health Center
at Kansas State University
1800 Denison Ave.
Manhattan, KS 66506
Tel: 785-532-5708
Fax: 785-532-4309
From: vvcemr-bounce@xxxxxxxxxxxxx<mailto:vvcemr-bounce@xxxxxxxxxxxxx>
[mailto:vvcemr-bounce@xxxxxxxxxxxxx] On Behalf Of Simon Roe
Sent: Thursday, October 02, 2014 8:00 AM
To: vvcemr@xxxxxxxxxxxxx<mailto:vvcemr@xxxxxxxxxxxxx>
Subject: [vvcemr] Diagnoses, Problems and Procedures
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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