Description of Health Service Encounter

(Author: Brent Jones – April 20^th, 2005)

ER visit (5.1.4) Storyboard: ER Visit (5.1)

Mabel is on an extended vacation with Cyril in their motor home in a rural area of another province when she starts to feel poorly with malaise, increased thirst and frequent urination. Being on vacation she has relaxed her attention to her diet and exercise. Along the way she has misplaced her glucometer and has not been able to check her sugars. She goes to the local ER there to be assessed. She has never been to this hospital before.

After being admitted to the ER, Mabel is taken to an examination room and assessed by the ER nurse who takes a history and records information into the ER’s EMR about the current illness. Unfortunately, Mabel is uncertain about any allergies. Furthermore, she forgot her medications in the motor home and can’t remember what she is on. She does recall the blood pressure pill she takes ran out a couple of days ago. The nurse obtains Mabel’s vital signs and records them in the EMR.

Mabel is then seen by Dr. Lafleur, a family physician from the area covering the ER that night. Mabel speaks no french but Dr. Lafleur speaks a bit of English and he is able to obtain some history of the present illness. It is more difficult to get a good description of her past medical history. Dr. Lafleur examines Mabel and finds a blood pressure of 148/98. He orders some blood tests, including blood glucose and creatinine, and a urinalysis.

While the Lab Clinician is with Mabel, Dr. Lafleur accesses her records and obtains her health profile. He also searches for her most recent lab results and consultation reports. From this, he is able to view the record of blood sugars and blood pressures Mabel has uploaded from home. In order to have full understanding of the consultant’s report that is written in English, Dr. Lafleur calls the translation service and gets a complete translation of the document. When the lab results he ordered are returned, Dr. Lafleur is able to compare these to the most recent obtained in Mabel’s home province. This collection of information gives Dr. Lafleur a good impression of Mabel’s current and past medical history and it becomes clear that she has had fairly good control of her blood pressure and sugar until recently. He obtains her current lab results and sees that in addition to her elevated blood pressure, Mabel has a urinary tract infection and a significant elevation of her blood glucose. He chooses to admit Mabel to the hospital and manage her infection, diabetes and blood pressure temporarily as an inpatient. Dr. Lafleur completes his record of the ER encounter in the hospital’s EMR and for it keeps a copy of Mabel’s past consultation and lab reports that he just viewed.

Assumptions

· Translation service exists and consents allow translator to view data

· Able to store data seen in EHR

Tables

Nursing Data

Record of Encounter

Health Service

This health service follows upon the patient home access (see 5.1.3) and describes all the health service events taken during the patient visit, for the first time, at a local hospital ER in rural area in another jurisdiction than that where she 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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