Use Case Diagram

Linda Lambert, 39, develops a sudden onset decreased visual acuity with pain in her right eye. She makes an appointment to see Dr. Black, her family physician, the next day.

When she arrives at the clinic, Linda stops first at the reception desk. The receptionist checks her in on the clinic ADT system and confirms that there has been no change in her demographic information, including name, address and telephone number.

Dr. Black takes the history of the current problem and does a pertinent physical exam. Linda reports having had a similar episode about 5 years prior that resolved fully. She saw her FP in the province she was living in at the time but can’t recall the details of the diagnosis or treatment. She remembers the symptoms settled and that she had been too busy at that time to follow through on a referral to an ophthalmologist that had been ordered. She has seen a few different optometrists in the past for routine eye exams. Dr. Black searches Linda’s records for encounters with diagnoses related to the eye and for encounters with optometrists or ophthalmologists, and finds a record of the encounter with her family doctor from her home province from 5 years ago, along with optometrists’ reports.

Dr. Black is concerned with his findings and makes an urgent referral to an ophthalmologist, who can see Linda the next day in his community office. Dr. Black completes his record of the encounter in his EMR. He also completes a consultation requisition letter outlining the current problem and sends it to the ophthalmologist.

· Able to search EHR based on multiple criteria including, but not limited to, provider, provider role, diagnosis, date of service, type of encounter

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

Patient name	Patient phone number
Patient date of birth	Patient healthcare number
History	Relevant past medical and ophthalmologic history
Doctor name	Doctor phone number
Doctor ID number	References to relevant documents

Health Service

This health service describes all the health service events taken during the patient visit at a family practice clinic in the jurisdiction where he lives; the patient is already a patient of this clinic. The patient has already lived in another jurisdiction.

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	4.1.1 Referral to Ophthalmologist Encounter Diagram
Type	Use Case Diagram

Description of Health Service Encounter

Health Service