Use Case Diagram

Cyril Lambert was recently treated at home for an exacerbation of his COPD and is now visiting friends in a rural town in another province. He goes to a family practice clinic there for the first time because his symptoms have not improved despite being on an antibiotic for 10 days. Cyril continues to have a productive cough for increased sputum and shortness of breath. He checks in at the clinic’s registration desk where the receptionist records demographic information and creates a paper chart for him. Cyril signs a consent form relating to the use of his health information. The receptionist records Cyril’s visit in the clinic ADT system.

Cyril is assessed by Dr. Smith who takes the history and quickly realizes Cyril’s current problem is likely an exacerbation of a chronic condition. Unfortunately, Cyril is a poor historian and doesn’t recall in any detail the tests he has had done, his diagnosis or the medications he has been prescribed. To try to clarify these issues, Dr. Smith uses her web browser to access the EHR portal and obtain a list of Cyril’s most recent encounters with the health system.

She specifies the five most recent encounters and is returned a list that includes interaction with:

Dr. Smith is able to follow links within each of these records to access more detailed information about each encounter. She is able to learn what tests were completed, the results of those tests, the medications that have been prescribed and filled, and the history of the most recent illness. She is able to bring up the chest x-ray and associated report from the radiologist. Using this information along with her own exam, Dr. Smith feels there is likely bacterial resistance to the antibiotic recently prescribed, in addition to poor compliance with the inhalers. She prescribes a different antibiotic and counsels Cyril on using the inhaled medications and quitting smoking. Dr. Smith completes her record of the encounter in Cyril’s paper chart and it is scanned by the clinic staff.

Name	Phone number
Address	Email
Birth date	Health care number
Emergency contact person	Emergency contact number

History	Physical exam
Provisional diagnosis	Management plan
Allergies	Medications
Past medical history

General Info
Name	1.1.1 New Family Physician Visit Encounter Diagram
Type	Use Case Diagram