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(Author: Brent Jones – April 12th, 2005)
Depression assessment (3.1.1)
Storyboard: Depression (3.1)
Hannah Lambert, 16, has recently become withdrawn and depressed, with lethargy, insomnia, worsening school performance. Hannah’s father and stepmother are very concerned and have her see their family physician, Dr. Black.
When she arrives at the clinic, Hannah stops first at the reception desk. The receptionist checks her in on the clinic ADT system and confirms with her that there has been no change in her demographic information, including name, address and telephone number.
Dr. Black attempts to get Hannah to talk about her current symptoms. She is not very forthcoming about how she is feeling but is occasionally tearful. She describes vague abdominal symptoms and hints at having had medical treatment lately. Dr. Black is concerned and decides to access Hannah’s records to see if there is any recent information there that might be relevant. He searches for the 10 most recent encounters and sees that there is masked information. Dr. Black asks Hannah about this and talks with her about the potential relevance. Eventually Hannah confides in Dr. Black what has happened and gives him permission to unmask the records. He is able to then view all of Dr. Singh’s clinical notes, the lab results and the pharmacy records. He has a clear picture of what has recently transpired and is able to get Hannah to open up more. Dr. Black diagnoses depression and recommends Hannah see a community psychologist and return for follow up. He creates an encounter note in his EMR.
Assumptions
·Permission can be given for a clinician to unmask data but not unmask for everyone to see
Tables
|
Name |
Phone number |
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Address |
|
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Birth date |
Health care number |
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Emergency contact person |
Emergency contact number |
|
History |
Past medical history |
|
Physical exam |
Provisional diagnosis |
|
Management plan |
This health service describes all the health service events taken during the patient visit to the family clinic in the jurisdiction where she lives; the patient is already registered at this clinic.
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.
| General Info | |
|---|---|
| Name | 3.1.1 Depression Assesment Encounter Diagram |
| Type | Use Case Diagram |
