Clinical Notes

Users stories

1. 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.
2. 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.
3. 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.
4. 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.