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Access Signed Chart Note in Other Form

MEL, SQL, Oracle

Last Post by Anonymous 1 second ago

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vrdlc

(@vrdlc)

Posts: 135

Estimable Member

Topic starter

Is it possible to access a signed chart note from within an encounter form? I have a referral form that needs to be filled out at patient referral, then a second form that other providers need to view later that contains the same saved data. It doesn't need to be modified, only read.

Does anyone know how to do this?

Posted : December 14, 2016 10:03 am

joeg1962

(@joeg1962)

Posts: 843

Noble Member

Unless I am misunderstanding your request, this would seem to be fairly straight-forward by building a VFE form. I build lots of forms that include data display (of OBS code) in addition to accepting input of new data.

For example, a form entry for cancer screenings - showing the last dates for mammo, pap, colorectal - and also the ability to enter new data.

Posted : December 15, 2016 3:52 am

vrdlc

(@vrdlc)

Posts: 135

Estimable Member

Topic starter

Looking back, I wasn't entirely clear. This goes beyond using OBS terms to call information from one form into another, in part because half of the data won't be put into OBS, as they don't exist/aren't important to track over time.

Here's what I'm trying to do:

I have a referral form that is filled out by the provider during an appointment with a client. This is a referral to a specific treatment program, so there is a lot of data that needs to be gathered, but that doesn't necessarily need to be saved into OBS terms or even saved over time. This data will really only be accessed once, in the next step of the process, when a committee of providers determine if this client is suitable for the treatment program.

Initially, I was going to use DOCUMENT variables, but when the chart note is signed, those values disappear, so that doesn't work. So basically what I need is to port the text of a chart note, the note that results from this referral form, into a second form that the committee is going to use in a new client encounter.

Is there a way to call an old document/chart note into a data field? The committee doesn't need to alter the data, they just need to see it. They can manually go into the client's history and open the document, but they'd rather have the process streamlined, and I don't blame them.

Posted : December 16, 2016 6:05 am

lkeith

(@lkeith)

Posts: 457

Honorable Member

I have not used this but I did find this and it may be referring to "forms within the same encounter":

In general a document variable included in one form will not be accessible to other forms. If there is a reason to share a variable between forms this can be done by checking the box to "Make available to other forms". However, in these situations it is important to choose a name that will be unique, and not something general, or you may run into conflicts as described above.

Posted : December 19, 2016 8:28 am

vrdlc

(@vrdlc)

Posts: 135

Estimable Member

Topic starter

This isn't what I mean either. I think I'm not being clear enough with what I'm looking to do.

When a provider completes a patient visit, they sign the chart note and it becomes a document in the patient history. What I want to do is take a previously signed chart note, open it up, and display its contents inside another form.
Here's the workflow:

Patient comes to provider with ISSUE X, and treatment needs to be discussed by a committee. The provider completes every aspect of this visit (vitals, prescriptions, specific care, etc.), including a referral form that documents this patient's history with ISSUE X and why they think the committee should consider this patient for treatment. The chart note is signed and becomes a document in the patient's medical history.

The next day, the committee gathers to determine which patients are eligible for ISSUE X treatment. Currently, they open up the client profile, pull out the document, find the referral information, then begin a new encounter that is solely for the committee to determine eligibility.

On this form, the Committee Form, I want to have a field (data, textbox, whatever) that holds the data that is inside that previous chart note. This is something I could do with OBS terms, but so many of the data points are only useful for the committee and don't need to be tracked, or they pertain to something that isn't specifically medical in nature and there isn't an OBS term for it.

I still have no idea where to start, so maybe it's just not possible.

Posted : December 21, 2016 12:20 pm

DavidShower

(@davidshower)

Posts: 1255

Noble Member

Look at mldefs6.txt, the objects _DocData, _GetMasterAndAppendedDocs, and _GetGroupDocsBySDID. One of those might get you what you are looking for. A chart note is stored as one or more rows in the DOCDATA table. If you take all the rows with the same SDID and copy and paste each DATA field into a text document (in order), you end up with an RTF document you can open in Word or Wordpad that is the chart note. Using one of those objects might get you what you are looking for. I've never worked with them so I'm not sure if it will work or not. Good luck!

Posted : December 21, 2016 12:36 pm

joeg1962

(@joeg1962)

Posts: 843

Noble Member

I would think you could approach as David suggests, or use an OBS term anyway. Pick an OBS term that is close in description (or not) but not used elsewhere in your system.

I have used OBS terms to pass data before. For instance, while no OBS codes obvious for it we pass info on reasons for social work referral, and then when our social work opens his/her note, they can see reason(s) for the referral.

Rather than a lot of programming to figure out a way to pass data, it would seem that to use an existing OBS code would be the simplest way. Is the text more than 2000 characters in the message? That might be the only concern.

Posted : December 22, 2016 12:33 am

gpincomb

(@gpincomb)

Posts: 278

Reputable Member

I understand that you do not want to use several Obs Terms to track data that is not reusable past the one follow-up chart document. We have similar forms where we only need data for the very next visit and what we have done is actually concatenate all of the pertinent data into one Document Variable and then right all of the concatenated data to a single Obs Term. I understand that this is not exactly what you want, but as far as I know this is the only easily accessible way of retaining the data. If you cannot find an Obs Term that best suits your needs, you can always request a new Obs Term built by GE, maybe something like "REFERDET" for Referral Details, their turnaround time is usually fairly quick. For most of our requests they provided a new Obs Term in less than 2 weeks.

Posted : December 22, 2016 7:30 am

lkeith

(@lkeith)

Posts: 457

Honorable Member

One thing you might keep in mind, maybe the information you are needing isn't needed long term, but if by having the information stored in an obsterm so it can be pulled, for whatever reason, then it is worth doing it.

Also, rather than thinking of pulling it into another form in the chart, we created a "worksheet" as a letter. We then went into Chart Reports and created inquires to pull a list of patients based on a certain criteria and saved them. Then the offices could go to Chart reports, run their inquiry and then go to Reports, find their "worksheet" letter and print off the worksheet for all of the patients that met the criteria in one step.

Just wanted to throw that out there for you to think about.

Posted : December 22, 2016 10:36 am

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