Thomas, maybe I'm too dense but I cannot appreciate the complexity of the issue as you hash it out.
To me this is simply: 3.5.2003 10:35 am first seen patient medium pain frontal skull after contusion in traffic accident 5 mins ago, no neurological abnormalities right now, GCS 15 3.5.2003 10:45 check up pain on pressure to 2nd cervical vertebra, dizziness, nausea, claims fuzzy vision, left pupil dilated responding to light slower than right, now severe pain frontal/retroorbital/ right temporal region. GCS 12. Clearly, there's some new and some updated information in this narrative. This is the point where I immediately ship the patient to the next CT/MRI scanning facility with on-duty neuro/neuro-surgery. All this requires is an append-only text field. Of course, it can be handled much more fanciful inside the EMR, trying to link items, graphing trends on scales, etc. etc. The basics, however, can be handled by free text fields. And even they do not just emulate the paper based record but offer one clear advantage: they are readable by me even if someone else wrote down the first assessment. > Narratives can be hard to handle in record-based systems as can scannable > entries, e.g., charts and images. But they are absolutely necessary. Karsten -- GPG key ID E4071346 @ wwwkeys.pgp.net E167 67FD A291 2BEA 73BD 4537 78B9 A9F9 E407 1346 - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
