I appreciate the recommendation, I also thought of placing such information under "Past History", but the real dilemma arises when new items take place *after* the initial encounter, particularly, in between visits.
So to use my inital example, If Ms. Smith calls two weeks after her initial appointment and reports that inderal makes her heart feel slow, where do I put that information? I can't add it to the "Past Medical History" field of the initial encouter because its been signed and locked. If I do add it there, I now am forced to save again the entire inital encounter as a new encounter (with the added clinical intervention), so now there are two differently dated initial encounters, differing only by the addition of the interval event. This becomes more problematic you use the "Past Encounters" tab feature because now there may be multiple past entries for the same initial encounter - when the initial encounter took place only once.
Ideally, there should be a section of the chart that remains alterable even when the rest of the chart has been signed/locked. - perhaps "Past Medial History" or perhaps adding a new "Intervention/Diagnostic" section to the chartt to which small entries in between visits could be sedquentially added without having to generate an entire new Clinical Encounter.
Other thoughts or ideas?
Bruce Morgenstern, MD (Neurology)
Denver, CO
