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(Author: Brent Jones – April 12th, 2005)
Telehealth consultation (3.1.4)
Storyboard: Depression (3.1)
Hannah Lambert has been diagnosed with depression and is on an antidepressant medication. Recently, her mood has heightened markedly, with Hannah becoming very much more outgoing, gregarious and somewhat hyperactive. She has developed insomnia and shown some impulsive decision-making. Her mother became concerned about such a dramatic shift in Hannah’s behaviour and took her to see Dr. Schwartz, their family doctor. Dr. Schwartz wonders if this is a manic episode and if Hannah’s diagnosis is actually bipolar affective disorder. She would very much like the input of a psychiatrist but there are none in her very remote rural area. Dr. Schwartz, therefore, makes a referral for a psychiatric Telehealth consultation.
Hannah presents to the local community hospital for the consultation. She registers with the admitting clerk who obtains Hannah’s full name, address, phone number, birth date and health card number, and enters the data into the hospital ADT system. The clerk obtains consent from Hannah regarding the storage and use of her health information.
Hannah is taken to the Telehealth unit and connected with the psychiatrist, Dr. Ho. She prepared for the consultation by reviewing Hannah’s records, including the referral request along with the clinical notes from the family doctors and psychologists referenced in the request. Once the consultation with Hannah is complete, Dr. Ho dictates a report of it.
Two days later, Dr. Ho reviews the typed consultation report and electronically signs it. A copy is sent to Dr. Schwartz.
Assumption
· The consultant will have consent to view the EHR before she has actually met the patient
Consultation report
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Patient name |
Patient birth date |
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History of present illness |
Past psychiatric history |
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Past medical history |
Medications |
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Allergies |
Examination |
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Provisional diagnosis |
Management plan |
This health service follows upon the referral to psychiatrist health service (see 3.1.3) and describes all the health service events taken during the patient visit for the first time to local community hospital (nearest Canadian Mental Health unit) in the jurisdiction where the patient moved.
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 | 3.1.4 Telehealth Consultation |
| Type | Use Case Diagram |
