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(Author: Brent Jones – April 12th, 2005)
TB First Assessment (10.1.1) Storyboard: TB (10.1)
John Cardinal, Linda Lambert’s nephew, is living with the Lambert while going to university. He is from a First Nation’s Reservation in another province. Over the last couple of weeks he has developed a cough with intermittent fevers. He goes to see a family physician, Dr. Gold, for the first time at the university’s health services.
When he arrives at the clinic, John stops first at the registration desk where the receptionist records demographic information about him. She searches for records on him and is returned three John Cardinals. She is able to determine which of these the correct record is for him. The receptionist creates a record of John’s visit in the clinic’s ADT system.
Dr. Gold assesses John. There is very little to find on exam and he feels the diagnosis is a viral upper respiratory tract infection. He prescribes symptomatic treatment and makes a record of the encounter in the EMR.
Assumptions
· The receptionist is able to resolve which of the John Cardinal records belongs to this person
Tables
|
Name |
Phone number |
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Current Address |
|
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Permanent Address |
Birth date |
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Health care number |
Emergency contact person |
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Emergency contact number |
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History |
Physical exam |
|
Provisional diagnosis |
Management plan |
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Allergies |
Medications |
|
Past medical history |
This health service describes all the health service events taken during the patient visit, for the first time, to the clinic of the university. The patient comes from another jurisdiction and he lives in the current jurisdiction while going to university.
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 | 10.1.1 TB First Assessment Encounter Diagram |
| Type | Use Case Diagram |
