# The Concepts used in the GNUmed EMR

## Synopsis

- encounter-oriented chronology
- problem-oriented documentation (POMR)
- SOAP structured progress notes
- optional aggregation of encounters into episodes of care
- optional aggregation of episodes into health issues
- problem list
- Lawrence L. Weed

If you know what this is all about you can stop reading here and jump to StartingGnumed.

## What it All Means

### The Encounter

An encounter is a one-off contact of a patient with the health care system. In a GP setting most encounters start when the patient enters the building and usually end when the patient leaves the building. Contact with a doctor may or may not have taken place. An encounter need not end on the day it started, eg when care is given over midnight the encounter will span a date boundary. Likewise there may well be two or even three encounters in one day (think of patients you see in the practice in the morning, send home but have to admit to hospital in the late evening).

Technically, in GNUmed an encounter need not always include human interaction. So over and beyond the usual patient-provider consultation the following situations are considered encounters, too:

- provider accesses the EMR without the patient being involved
- an automated process (such as an importer script for, say, lab data) accesses the medical record

### Problem-Oriented Documentation of Care

This means that all recorded clinical data is associated with an explicitly stated problem suffered by a patient. Problems need not be diagnoses. They need not be hard scientific facts. They can be syndromes, they can be findings, they can be history items. Over time they are likely to merge and consolidate into well-founded diagnoses. Or they may not. That is the beauty of GP level healthcare.

Note that during one single encounter several problems with the patient's health can be dealt with.

### The SOAP Schema

In 1964 Lawrence L Weed introduced the SOAP structuring of progress notes in medical records. This concept roughly says that all clinical data associated with giving care to a patient is to be grouped into the categories Subjective, Objective, Assessment, and Plan. Various criticisms have been put forth as to where this classification lacks sophistication or falls short of properly capturing clinical information. However, setting aside academically-proper validation and evaluation, most clinical data at the GP level can be grouped into one of:

- Subjective
  - what the patient narrates
- Objective
  - what findings were elicited at the encounter in question
- Assessment
  - what does the clinician think Subjective/Objective mean to the patient's health
- Plan
  - what do patient and clinician (intend/plan to) do about the patient's health

Each problem will have its own dedicated SOAP-structured data.

### The Episode of Care

In the course of possibly several encounters a few health problems will be worked on. The time from the first until the last encounter for a given problem is the corresponding episode of care. It is entirely at the discretion of the clinician how long the episode lasts. Usually an episode will only be recognized as "case closed" when the patient does not report back for an extended period of time.

Each episode of care may comprise one or several encounters. While GNUmed does not yet model this visually, an analogy based on an example at Dipity, may inform. Encounters would distributed from left to right along the patient's time line. Episodes would be stacked vertically, each episode a horizontal stripe, positioned at an _arbitrary height, its left edge determined by its start date, and its right edge defined by its end date, if one has been defined.

An episode may be associated with a health issue.

### The Health Issue

At times the clinician will recognize a cluster or subset of distinct episodes of care as looking suspiciously related. In such cases it may make sense to group them under one health issue. Thus, health issues are fundamental issues with a patient's health. They may be active or inactive. Post-MI state is likely to be clinically relevant for the rest of the patient's life. It may not be an active problem at a given time, however. OTOH a traumatically amputated finger will always be both clinically relevant and active if it confers ongoing disability. Health issues will more often be expressed as diagnoses than will "problems". In GNUmed, past medical history items will mostly be stored as health issues.

Each health issue aggregates one or several episodes of care.

### The Problem List

The problem list (the list of active problems) consists of items being worked on, or kept in mind, while trying to improve the health of the patient. This list includes the clinically relevant health issues and the open episodes. Health issues marked as clinically not relevant are not included, nor are closed (inactive) episodes.

## Putting Things Together

The structure of a patient's EMR can be seen as a tree:

* health issues aggregate clinically-related episodes of care

- episodes will have data added to them during one or several encounters
  - such data is grouped into the SOAP schema

* a further treatment of how this works, but which you may rather skip for the moment, is initiated at EncounterEpisodeIssue

Next: Starting Gnumed

## Literature

(sorted by lastnames of authors)

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- Soler JK. Sick leave certification: a unique perspective on frequency and duration of episodes - a complete record of sickness certification in a defined population of employees in Malta. BMC Fam Pract. 2003 Mar 27;4:2. Epub 2003 Mar 27. (PMID: 12697050 )
- Son RY, Taira RK, Bui AA, Kangarloo H, Cardenas AF. A context-sensitive methodology for automatic episode creation. Proc AMIA Symp. 2002;:707-11. (PMID 12463916)
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- Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. (PMID: 5637758)
- Weed LL. Medical records that guide and teach. 1968. MD Comput. 1993 Mar-Apr;10(2):100-14. (PMID: 8469091)
- Wingert TD, Kralewski JE, Lindquist TJ, Knutson DJ. Constructing episodes of care from encounter and claims data: some methodological issues. Inquiry. 1995-1996 Winter;32(4):430-43. (PMID: 8567080)