11/20/2013, Encounter Note - Concern ID A.1 previously recorded Create Concern A.1 10:17am Assessment: with additional history. Diabetes, Type 1, Controlled 3/4/2014, Registration Concern ID A.2 start of a new Create Concern A.2 – 2:45pm Complaint: & concern on system A, and current Dyspnea name of the concern. 3/4/2014, Encounter Concern ID A.2 - the exam finding Add to A.2 2:50pm Note.Exam: No was recorded in the complaint Wheeze context Exam “Cough/Dyspnea”. findings would generally be used as naming observations. 3/4/2014, Encounter Note. Concern ID A.2 - complaint context Add Event to A.2 2:50pm Assessment: of encounter. In the note, the Probable Viral URI Assessment/Plan section, the (sometimes called “Assessment” is an observation “Impression”) event that names the concern at a point in time. The name of the concern is now Viral “Probable URI” 3/11/2014, Registration Concern ID A.3 A might, Create Event A.3 – 9:23am Complaint: without being aware of the existing Dyspnea Fever concern, create a new concern. That can be corrected by merging with concern ID A.2 after it is realized this represents the same complaint/concern. As the concern is merged, the name of the concern is selected from one or the other. 3/11/2014 Concern ID A.2 complaint context Add Event to A.2 9:38am Crackles, No Wheeze 3/11/2014, Concern ID A.2 complaint context. Rename Concern 9:38am This is the new name of the concern A.2 Possible A.2 Community Acquired Pneumonia 3/11/2014, Order: Concern ID A.2 - placed from Add Event to A.2 9:38am Azithromycin context 3/11/2014, Orders: Laboratory Concern ID A.2 placed from Add Event to A.2 – 9:38am context 3/11/2014, Lab.WBC Concern ID A.2 result is ordered Add Event to A.2 12:10pm under this context
11/20/2013, 10:17am Encounter Note - Assessment: Diabetes, Type 1, Controlled Concern ID A.1 previously recorded with additional history. Create Concern A.1 3/4/2014, 2:45pm Registration Complaint: & Dyspnea Concern ID A.2 – start of a new concern on system A, and current name of the concern. Create Concern A.2 3/4/2014, 2:50pm Encounter Note.Exam: No Wheeze Concern ID A.2 - the exam finding was recorded in the complaint context “Cough/Dyspnea”. Exam findings would generally be used as naming observations. Add to A.2 3/4/2014, 2:50pm Encounter Note. Assessment: Probable Viral URI Concern ID A.2 - complaint context of encounter. In the note, the Assessment/Plan section, the “Assessment” (sometimes called “Impression”) is an observation event that names the concern at a point in time. The name of the concern is now “Probable Viral URI” Add Event to A.2 3/11/2014, 9:23am Registration Complaint: Dyspnea Fever Concern ID A.3 – A might, without being aware of the existing concern, create a new concern. That can be corrected by merging with concern ID A.2 after it is realized this represents the same complaint/concern. As the concern is merged, the name of the concern is selected from one or the other. Create Event A.3 3/11/2014 9:38am Crackles, No Wheeze Concern ID A.2 complaint context Add Event to A.2 3/11/2014, 9:38am Possible Community Acquired Pneumonia Concern ID A.2 complaint context. This is the new name of the concern A.2 Rename Concern A.2 3/11/2014, 9:38am Order: Azithromycin Concern ID A.2 - placed from context Add Event to A.2 3/11/2014, 9:38am Orders: Laboratory Concern ID A.2 – placed from context Add Event to A.2 3/11/2014, 12:10pm Lab.WBC Concern ID A.2 result is ordered under this context Add Event to A.2