PatientOS Open Source EMR

We create new clinical document forms by building one reusable section at a time and then combining them into a single form.

First we login as admin/admin and click on the clinical sections link.

Step 1 Form Design

In this example we are going to create a new system form called Family History with the following goals in mind.

• Break the form into reusable sections.
• Add the data elements using OpenEHR archetypes where possible.
• Map terms to SNOMED where possible.

Step 2 Family Health History Design

• Sections - we will break the form by site.
• Data elements will come from the openEHR-EHR-EVALUATION.risk-family_history archetype.
• (EDIT) Due to disparities in the archetype we added a new group of data elements called Family History.
• SNOMED findings will be used for each record.

Step 3 Data Elements

1. Login as admin/admin
2. Open the Data Elements tool (right click on nodes to get the menu).
3. Create subcategory History and Physical –> Past Medical History –> Risk Family History
4. Find the archetype using http://www.openehr.org/knowledge/
5. Import the Archetype into that category.
6. (EDIT) we added a subcategory History and Physical –> Past Medical History –> Family History
7. (EDIT) we added 3 data elements
   - Family History Condition
   —- Integer
   —- Positive/Negative
   - Family History Patient Relative
   —- String
   —- Value List: PatientRelative
   - Family History Condition Notes
   —- String

Step 4 Terms

1. Open the Terms tool (right click on tree nodes).
2. Create term category History and Physical –> Past Medical History –> Family History.
3. Create all new subcategories e.g. System Family History Eyes.
4. Find the concept ids using http://eagl.unige.ch/SNOCat/.
5. Add terms selecting the appropriate subcategory
6. Search for the concepts in PatientOS in the format <conceptid>|<conceptid>|.. etc.
7. Repeat with each new subcategory.
8. We also add a free text term ‘Other’ for the subcategory.

Multiple concept SNOMED search

Concept search by multiple IDs

Step 5 Create Form

1. Open the Clinical Sections tool
2. Create a new form for the first section System - Family History Eyes
3. We view the form properties
   - change the columns to 4.
   - add a custom column definition “1dlu, 1dlu, 1dlu, max(75dlu;p), 1dlu, 1dlu, 1dlu, max(25dlu;p), 1dlu, 1dlu, 1dlu, max(50dlu;p), 1dlu, 1dlu, 1dlu, max(75dlu;p)”
4. We add 4 labels, one per column
   - Condition
   - Present?
   - Relation
   - Notes
5. We then add 4 controls
   - Condition
   —- Custom Term Display Field
   —- Record Item: Family History Condition
   —- Term: Cataract
   - Present?
   —- Custom 3 state field
   —- Record Item: Family History Condition
   —- Term: Cataract
   - Relation
   —- Pick list
   —- Record item: Family History Relation
   —- Term: Cataract
   - Notes
   —- Free Text field
   —- Record Item: Family History Condition Notes
   —- Term: Cataract
6. We then copy the 4 controls and paste as 4 new controls
7. Select the 4 new controls and press the Term toolbar button to change the term to Glaucoma for all 4
8. Repeat 6-8 for the term Other in the Family History Eyes category
9. Save the form
10. Repeat for all form sections

This entry was posted on Monday, October 20th, 2008 at 7:59 pm and is filed under Physician Documentation. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.