Description of Health Service Encounter

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

TB Diagnosis (10.1.4) 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. In the second semester of his first year there, John develops an acute illness with a cough and fever. He has seen his family physician, Dr. Gold, at the university’s health services on a couple of occasions regarding this illness and has had some investigations done. A chest x-ray was done recently and showed a small pleural effusion. Dr. Gold is wondering about tuberculosis (TB) and performed a Mantoux test two days ago. John has returned to the clinic as scheduled for interpretation of the test.

Dr. Gold measures the induration and determines the test is positive. He is concerned that this might be active TB infection. To try to clarify this, Dr. Gold reviews John’s health profile and finds no record of BCG vaccination or prior TB infection. He decides to treat this as an active infection, so he prescribes the appropriate antibiotics and completes the Active Tuberculosis Report Form for Public Health. He also creates a record of the encounter for his clinic’s EMR.

Assumptions

· A copy of the report form is kept on the EHR and that this is a trigger for public health to act on it

Tables

Health Profile

Record of Encounter

Health Service

This health service follows upon the DI report (see 10.1.3) and describes all the health service events taken during the patient visit to the clinic of the university. The physician is wondering about tuberculosis (TB) and performed a Mantoux test. The patient has returned to the clinic as scheduled for interpretation of the test.

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.

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