Description of Health Service Encounter

(Author: Brent Jones – April 12^th, 2005)

Community health centre (6.1.1) Storyboard: ACL Injury (6.1)

Dr. David Lambert, 40, suffers a significant pivot-type injury to his right knee while hiking on uneven ground on a vacation in one of the territories. Late that night, he takes a non-steroidal anti-inflammatory medication (NSAID) for the first time. The next morning he has considerable pain and swelling in his knee and has developed an urticarial rash over his body. He is taken by his companions to the local community health centre for assessment by the nurse practitioner there.

The nurse practitioner takes a history of the injury and examines the knee and rash. She feels David has sprained the knee and possibly torn the cartilage. She also feels he has had an allergic reaction to the NSAID. Given the significant joint swelling, the nurse practitioner thinks the knee should be x-rayed to rule out a fracture and makes arrangements for David to be seen at the nearest hospital ER. Before David leaves, she accesses his records and views his health profile containing his list of allergies, and gives him an intramuscular injection of a narcotic analgesic. The nurse practitioner completes her note of the visit in her EMR.

Assumptions

·The health profile exists as a unique document

·Anyone can update a health profile

Tables

Record of Encounter

Health Service

This health service describes all the health service events taken during the patient visit, for the first time, to the local community health center in there jurisdiction where he lives.

Each health service event takes place during a same period of time (e.g. without cut of time), in presence or not of involved client; the health service events can be grouped in a health service encounter.

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