[vvcemr] Re: Diagnoses, Problems and Procedures
- From: Simon Roe <Simon_Roe@xxxxxxxx>
- To: VetView Med Rec list <vvcemr@xxxxxxxxxxxxx>
- Date: Wed, 8 Oct 2014 07:44:35 -0400
The problem with using a billable event for procedure is that there will be
many instances where it will not be specific enough. The procedure request
does not always fully reflect what was done during the procedure, because
we don't always know beforehand. Information has to be entered after the
event has occurred. It will work for some. I would strongly support the
development of a Procedures List for all to use
Simon Roe
On Mon, Oct 6, 2014 at 10:10 AM, Shirley T. Arck <sarck@xxxxxxxxxxxxxxx>
wrote:
> 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
> <vvcemr-bounce@xxxxxxxxxxxxx>] *On Behalf Of *Simon Roe
> *Sent:* Thursday, October 02, 2014 8:00 AM
> *To:* 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
>
>
>
> "Live fully. Love wastefully. Be all that you can be." adapted from Bishop
> Spong
>
>
>
> 'All electronic mail messages in connection with State business which are
> sent to or received by this account are subject to the NC Public Records
> Law and may be disclosed to third parties.'
>
--
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
"Live fully. Love wastefully. Be all that you can be." adapted from Bishop
Spong
'All electronic mail messages in connection with State business which are
sent to or received by this account are subject to the NC Public Records
Law and may be disclosed to third parties.'
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