Clinical Notes
- Gilbert Muthee
- Wamathaga Kamau
Users stories
Documentation of Care:
Actor: Clinician
Scenario:
As a clinician, I want to take a basic patient history using a structured form so as to document my findings and management plan.
Continuity of Care:
Actor: Clinician
Scenario:
As a clinician, I want to use a structured form to maintain continuity of care.
The EMR system allows the clinician to review previous notes easily before each patient encounter.
This ensures a comprehensive understanding of the patient's medical history and ongoing management.
Multidisciplinary Collaboration:
Actor: Clinician, Other Healthcare Providers
Scenario:
As a clinician collaborating with other healthcare providers, I want to use clinical notes to communicate effectively.
The clinical notes provide a standardized format for documenting patient information that can be easily shared among different specialties or departments.
This supports coordinated care and seamless handoffs between healthcare team members.
Referral and Consultation Notes:
Actor: Clinician, Specialist
Scenario:
As a clinician referring a patient to a specialist, I want to document the referral details.
The SOAP note includes a section for documenting the reason for referral, relevant patient information, and the specialist's recommendations.
This supports effective communication between primary care providers and specialists.
Appointments:
Actor: Healthcare workers
As a healthcare workers i would like to schedule a patients appointment to review their progress at a later date.
Scenario:
Technical approach
Adopt with modifications what Palladium has as the clinical encounter to act as a generic OPD form in the refApp for a structured history and improved SOAP notes for unstructured history.