1 Description of Health Service Encounter

(Author: Brent Jones – April 12^th, 2005)

LTC Facility (7.1.5) Storyboard: CVA (7.1)

Cyril Lambert has been residing in a long term care facility for about one year following his stroke. His lung function has continued to deteriorate as a result of chronic obstructive pulmonary disease and, with it, his overall functional abilities.

Cyril recently developed another respiratory tract infection. He has become very weak and is having greater and greater difficulty breathing. Cyril and his family had previously decided with Dr. Martin that attempts will not be made to resuscitate him should the situation arise. This wish has been recorded in Cyril’s EMR as a patient directive.

Late one night Cyril’s condition deteriorates markedly and he passes away. The nurse who was with Cyril when he died makes a record of the event in the facility’s EMR and notifies Dr. Martin. Dr. Martin comes in and pronounces Cyril deceased. He completes the provincial Registration of Death form electronically.

Assumptions

· Patient directive can be recorded in EMR and uploaded to EHR

· Registration of Death forms (or whatever they are called in each province) can be completed electronically and are uploaded to the EHR

Tables

Nursing Notes

Registration of Death Form

Health Service

This health service follows upon the home care (see 7.1.4) and describes some health service events taken during that the patient resides in a long term care facility.

The patient also obtained other health services encounters for a chronic obstructive pulmonary disease (COPD – see 1.1.1); at this period, a health service encounter took place 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.

Get SVG Format