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(Author: Brent Jones – April 12th, 2005)
Referral to DM Clinic (5.1.1) Storyboard: Diabetes (5.1)
Mabel Lambert, 55, recently had a physical exam done by her family physician, Dr. Martin. During that exam, Dr. Martin had reviewed Mabel’s family history in her records and noted her parents had had type II Diabetes mellitus. Mabel is heavy set with little physical activity so he had ordered a fasting blood glucose and HbA1C level on her. The results returned consistent with diabetes. Dr. Martin had his clinic nurse call Mabel in to discuss.
Dr. Martin reviews Mabel’s lab results with her and counsels her on diabetes. Together, they decide she will start managing her diabetes with diet and lifestyle changes. Dr. Martin also chooses to refer Mabel to the diabetes clinic in their local rural hospital. He creates a record of the encounter in Mabel’s EMR and completes a referral for the consultation.
Tables
Record of Encounter
|
History |
Physical exam |
|
Lab results |
Provisional diagnosis |
|
Management plan |
Referral to Diabetes Clinic
|
Patient name |
Patient phone number |
|
Patient date of birth |
Patient healthcare number |
|
History |
Relevant past medical and surgical history |
|
Social history |
Physical exam findings |
|
Lab results |
DI results |
|
Doctor name |
Doctor phone number |
|
Doctor ID number |
References to relevant documents |
This health service describes all the health service events taken during a follow-up of a patient by his family physician.
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 | 5.1.1 Referral to DM Clinic Encounter Diagram |
| Type | Use Case Diagram |
