How to Keep the EMR Nicely Structured
If you did not already familiarize yourself with (or forgot about) GNUmed's GUI tools - like its phrasewheels to assist searching and drop-down list completion - remind yourself here.
Adding Clinical Data
In the progress notes creator one can select the episode under which a SOAP note is to be saved. This can be done by selecting a problem from the problem list. If the problem is a health issue (eg. past medical history item) a new episode is created for that health issue. If the selected problem is an existing episode the data will be saved under that episode. One can also opt to create an entirely new episode that is not attached to any health issue as of the time being. New health issues (in other words past medical history items) will be able to be added from any progress note editor by typing the keyword "phx$" and filling in the popup dialog. The keyword may be different if your GNUmed installation is set up for another country.
The GNUmed tree system was made so that a Health Issue would have Episodes attached to it.
Encounters are generated automatically by the system.
Regrouping of, Editing, and Deleting Clinical Data
Health issues and episodes can be edited, deleted and regrouped from the tree view of the EMR. Right-click on a tree item to pop up a context menu.
SOAP data can not yet be edited or moved to another encounter from within the GNUmed client. It can only be amended by adding to it. It can, however, be attached to an episode different from the original one. It may be beneficial to use a closed-by-default, dedicated episode "deprecated clinical entries" to which "corrected" clinical data can be attached if desired.
Encounters cannot be explicitly deleted from within the GNUmed client. Their summary and timestamp details, however, can be edited which may make them appear to "move" in time (if start/end timestamps are changed). "Old" empty encounters will be cleaned out by the system eventually where "old" is a configurable duration of time. "Empty" in this context means that there
is no clinical data (narrative, documents, allergies, etc.) attached to it.
Family History and other Special Patient History
These will be better-supported in later versions of GNUmed but for now are only tidily manageable inside the health issue or Unattributed issue episodes structure. More information is available on the rough page FamilyHistory.
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