|
(Author: Brent Jones – April 12th, 2005)
Dental visit (12.1.1) Storyboard: Dental (12.1)
Tim Lambert, 15, is on a week-long school trip to another province when he develops pain in a tooth. He is having great difficulty eating or drinking anything so is taken by one of the chaperones to a local dentist.
The dentist, Dr. Armstrong, sees Tim and takes a history of the current problem. He examines the tooth and takes an x-ray. Dr. Armstrong diagnoses a dental caries and recommends removing the carious material and filling the tooth. Tim agrees to go ahead with the procedure.
Dr. Armstrong asks some screening questions regarding allergies and past medical history, such as heart problems. Tim is uncertain about allergies. He recalls some confusion as to whether he or his twin brother had problems with an antibiotic a number of years ago. Tim remembers that he was investigated for a heart problem after he nearly fainted while playing soccer when he was 10 years old. He can’t recall what was diagnosed. Unfortunately, Tim’s parents are not with him on this trip to provide some answers.
Dr. Armstrong accesses Tim’s records and reviews his health profile. He notes no allergies to any medications and sees no major conditions listed under his past medical history. Dr. Armstrong searches for heart-related diagnoses in Tim’s records and finds a consultation report from a cardiologist along with an echocardiogram report from five years ago. These confirm the presence of a benign heart murmur. Dr. Armstrong is confident Tim has no medication allergies and does not require antibiotic prophylaxis.
Dr. Armstrong completes the procedure and creates a record of the encounter in his EDR.
Assumptions
· Able to search clinical records based on specific criteria such as class of diagnosis
· Dental records are sent to EHR
Tables
Record of Encounter
|
History |
Exam |
|
X-ray findings |
Allergies |
|
Provisional diagnosis |
Management plan |
|
Medications |
Past medical history |
This health service describes all the health service events taken during the patient visit, for the first time, at the local dentist in a jurisdiction where he is on a week-long school trip.
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 | 12.1.1 Dental visit Encounter Diagram |
| Type | Use Case Diagram |
