Requirements: Patient Notes

Background

In all the clinical interviews we've conducted, the Notes function in an EMR ranks as one of the top 2-3 features both clinically needed and most frustrating for clinicians.

• clinicians need to be able to see the history of the patient with the notes inline, ordered by date but also contextually associated with visits, procedures, labs, pharmacy, etc.
• clinicians need to clearly see who offered the note.
• clinicians want it to be straightforward to add/edit a note, regardless of where they are in a patient record.

Data Model

Thus, notes are a list that is associated to a patient, yet they can have have nested associations to:

• Patient History
• Social Work
• Visits
• Procedures
• Labs
• Imaging
• Pharmacy
• Other / General

An ideal interface would present the patient history as a series of chronologically-ordered notes, with the various objects both embedded (and clickable) in the history.

For instance, for each visit, the history of the visit would be clearly visible through the Notes.

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