Description of Health Service Encounter

(Author: Brent Jones – April 11^th, 2005)

Infection diagnosis (2.1.1) Storyboard: Sexually Transmitted Infection (2.1)

Hannah Lambert, 16, happens to hear at school that a recent partner has Chlamydia. She is concerned she might also have an infection so attends a walk-in clinic for the first time, rather than go to her family’s usual physician.

Hannah checks in with the clinic receptionist who confirms she has never been there before. She obtains Hannah’s full name, birth date, provincial health care number and contact information and creates an encounter record in the clinic’s ADT system. She also obtains Hannah’s consent regarding the storage and use of health information by the clinic and creates a new file for her in the clinic’s EMR.

The clinic physician that day, Dr. Singh, assesses Hannah and does a pelvic exam with a Pap smear and swabs for gonorrhoea and Chlamydia. Hannah tells Dr. Singh she would like to have all of the records related to this visit masked so that there is no chance her father, a physician, might see them. Dr. Singh completes his record of the encounter in the clinic EMR.

Assumptions

·Able to mask clinical data, encounter record

·Able to retroactively mask encounter record

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 a clinic in the jurisdiction where the patient 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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