Difference between revisions of "Pain History LBF"

From OpenEMR Project Wiki
 
(39 intermediate revisions by 2 users not shown)
Line 1: Line 1:
===='''Introduction'''====
This page is a work in progress. Please check back periodically, thanks!
Layout-based forms (LBFs) are quite versatile. If you are not familiar with LBF's, check this out this page.
=='''Introduction'''==
Layout-based forms (LBFs) are quite versatile. If you are not familiar with LBFs, check out this page.


First some definitions:
===Definitions===
First some definitions. We all need to be on the same page. What may be a form to a programer, may mean something totally different to a provider.
Terminology clarification:
Terminology clarification:
Form:
::Form:
A form is a user interface element within a website or software application that allows you to enter and submit data. It contains one or more fields and an action button, such as Save or Submit.
"A form is a user interface element within a website or software application that allows you to enter and submit data. It contains one or more fields and an action button, such as Save or Submit."
from: [https://techterms.com/definition/form#:~:text=A%20form%20is%20a%20user,such%20as%20Save%20or%20Submit techterms].
[https://techterms.com/definition/form#:~:text=A%20form%20is%20a%20user,such%20as%20Save%20or%20Submit techterms.com].
Hence, a form, is not a progress note. A form may be used to gather information from the patient, or from the provider in order to be entered into the database.


Progress note:
::Progress note:
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care.
"Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care."
https://en.wikipedia.org/wiki/Progress_note#:~:text=Progress%20Notes%20are%20the%20part,the%20course%20of%20outpatient%20care.
[https://en.wikipedia.org/wiki/Progress_note#:~:text=Progress%20Notes%20are%20the%20part,the%20course%20of%20outpatient%20care wikipaedia]. Hence, a progress note may be entered into the record via the use of a form.  


Report: in the administrative term vs the clinical term
::Reports:
an account given of a particular matter, especially in the form of an official document, after thorough investigation or consideration by an appointed person or body.
In the administrative term versus the clinical term, the word report may mean several different things.
Oxford dictionary
According to [https://languages.oup.com/google-dictionary-en/ Oxford languages] a report is "an account given of a particular matter, especially in the form of an official document, after thorough investigation or consideration by an appointed person or body."
:::Clinic note report:
In healthcare, in order for a specialist to get reimbursed at a higher level, he/she must have a referral from a referring physician, and must send back a report within a specific amount of time.
Hence, a report is a document that is generated after an encounter/visit in order to be sent back to the referring physician.


Custom report:
However, a report may also be custom
A Custom Report is a report that you create. You pick the dimensions (City and Browser, for example) and metrics (Sessions, Pageviews, and Bounce Rate, for example) and decide how they should be displayed. You must specify at least one dimension and one metric.
 
:::Custom report (as in healthcare administration):
A Custom Report is a report that you create. You pick the dimensions (City and Browser, for example) and metrics (Sessions, Pageviews, and Bounce Rate, for example) and decide how they should be displayed. You must specify at least one dimension and one metric ([https://support.google.com/analytics/answer/1033013?hl=en google analytics]).
Hence, this type or report can be generated in order to evaluate a specific measure, such as the visits for today, the number of patients that are indigent, or who have BCBS for example.
 
So, let us all speak the same language as best as possible.
 
===Planning your LBF===
Planning your LBF, refer to the pain history form below:
 
Observe that the form includes certain lists:
::Body parts
::Laterality (optional, for example, if a chiropractor addresses only the spine and wants to use neck, thoracic and lumbar in body parts, this list could include mid, right, left, bilateral)
::Injury type
::Scale from 1 to 10
::Type of treatment
::Exacerbating factors
::Alleviating factors
::Associated symptoms
yes/no and boolean yes/no are already in the current distribution, however, I add N/A to the boolean list. Say for example you are seeing a patient for the first time, some questions in the form may not be applicable.
 
The lists that you create will depend on the data that you are interested in tracking. Once the lists are created, work on the LBF can begin.
 
 
===='''Sample LBFPainhx:'''====
 
:[[File:LBFPainhx-rendered1.png]]
:[[File:LBFPainhx-rendered2.png]]
 
 
===='''Four column view of a form'''====
This image is included to help you visualize the columns in a form, you may design your form to be a 4 column form as this image, or to be a 6 column form, or whatever you choose. The OpenEMR default is a 4 column form.
 
:[[File:4columns.png]]


===='''Alphabetic list (as of v6.1.0):'''====
===='''Alphabetic list (as of v6.1.0):'''====
Line 26: Line 65:
! Data type !! Size !! List  !! Backup List  
! Data type !! Size !! List  !! Backup List  
|-
|-
| Billing codes ||  
| Billing codes || || || ||
|-
|-
| checkboxes || number of sub-columns boxes are arranged into
| checkboxes || number of sub-columns boxes are arranged into || X || ||
|-
|-
| checkboxes with text || field's width in the form
| checkboxes with text || field's width in the form || X || ||
|-
|-
| exam results || field's width in the form
| exam results || field's width in the form || X || ||
|-
|-
| facilities(v4.1.1) ||  
| facilities(v4.1.1) || || || ||
|-
|-
| image canvas ||  
| image canvas || || || ||
|-
|-
| insurances ||  
| insurances ||  || || ||
|-
|-
| lab results(v6.0.0.4) ||  
| lab results(v6.0.0.4) ||  || || ||
|-
|-
| lifestyle status(v4.0.0) ||  
| lifestyle status(v4.0.0) ||  || || ||
|-
|-
| list box || || X || X ||
| list box || || X || X ||
Line 58: Line 97:
| multiple select list(v4.2.0) ||  || X || X ||
| multiple select list(v4.2.0) ||  || X || X ||
|-
|-
| Nation notes(v4.1.0) ||  
| Nation notes(v4.1.0) || || X || ||
|-
|-
| organizations ||  
| organizations ||  || || ||
|-
|-
| patients(v6.1.0) ||  
| patients(v6.1.0) ||  || || ||
|-
|-
| patient signature(v5.2.1) ||  
| patient signature(v5.2.1) ||  || || ||
|-
|-
| patient allergies ||  
| patient allergies ||  || || ||
|-
|-
| pharmacies ||  
| pharmacies ||  || || ||
|-
|-
| previous names(v6.1.0) ||  
| previous names(v6.1.0) ||  || || ||
|-
|-
| providers ||  
| provider's ||  || || ||
|-
|-
| providers NPI ||  
| providers NPI ||  || || ||
|-
|-
| race/ethnicity(v4.0.0) ||  
| race/ethnicity(v4.0.0) ||  || || ||
|-
|-
| radio buttons(v3.2.0) || number of sub-columns buttons are arranged into
| radio buttons(v3.2.0) || number of sub-columns buttons are arranged into || X || ||
|-
|-
| smoking status(v4.0.0) ||  
| smoking status(v4.0.0) ||  || || ||
|-
|-
| squads ||  
| squads ||  || || ||
|-
|-
| static text(v4.0.0) ||  
| static text(v4.0.0) ||  || || ||
|-
|-
| text state ||  
| text state ||  || || ||
|-
|-
| text area || "cols" value
| text area || "cols" value || || ||
|-
|-
| text box || field's width in the form
| text box || field's width in the form || || ||
|-
|-
| text box list || field's width in the form
| text box list || field's width in the form || || ||
|-
|-
| user signature(v5.2.1) ||  
| user signature(v5.2.1) ||  || || ||
|-
|-
| visit categories ||  
| visit categories ||  || || ||
|}
|}
Please note that if the version of OpenEMR is not in parenthesis, the data type may predate v2.7.0
Please note that if the version of OpenEMR is not in parenthesis, the data type may predate v2.7.0


===='''Sample LBFPainhx:'''====
==Resources==


:[[File:LBFPainhx-rendered1.png]]
::[https://www.open-emr.org/wiki/index.php/LBV_Forms Layout based visit forms]
:[[File:LBFPainhx-rendered2.png]]
::[https://www.open-emr.org/wiki/index.php/Sample_Layout_Based_Visit_Form Sample LBF]
 
::[https://www.open-emr.org/wiki/index.php/LBV_FORMS_FOR_OPHTHALMOLOGY LBF for ophthalmology]
 
===='''Four column view of a form'''====
:[[File:4columns.png]]

Latest revision as of 13:27, 15 April 2022

This page is a work in progress. Please check back periodically, thanks!

Introduction

Layout-based forms (LBFs) are quite versatile. If you are not familiar with LBFs, check out this page.

Definitions

First some definitions. We all need to be on the same page. What may be a form to a programer, may mean something totally different to a provider. Terminology clarification:

Form:

"A form is a user interface element within a website or software application that allows you to enter and submit data. It contains one or more fields and an action button, such as Save or Submit." techterms.com. Hence, a form, is not a progress note. A form may be used to gather information from the patient, or from the provider in order to be entered into the database.

Progress note:

"Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care." wikipaedia. Hence, a progress note may be entered into the record via the use of a form.

Reports:

In the administrative term versus the clinical term, the word report may mean several different things. According to Oxford languages a report is "an account given of a particular matter, especially in the form of an official document, after thorough investigation or consideration by an appointed person or body."

Clinic note report:

In healthcare, in order for a specialist to get reimbursed at a higher level, he/she must have a referral from a referring physician, and must send back a report within a specific amount of time. Hence, a report is a document that is generated after an encounter/visit in order to be sent back to the referring physician.

However, a report may also be custom

Custom report (as in healthcare administration):

A Custom Report is a report that you create. You pick the dimensions (City and Browser, for example) and metrics (Sessions, Pageviews, and Bounce Rate, for example) and decide how they should be displayed. You must specify at least one dimension and one metric (google analytics). Hence, this type or report can be generated in order to evaluate a specific measure, such as the visits for today, the number of patients that are indigent, or who have BCBS for example.

So, let us all speak the same language as best as possible.

Planning your LBF

Planning your LBF, refer to the pain history form below:

Observe that the form includes certain lists:

Body parts
Laterality (optional, for example, if a chiropractor addresses only the spine and wants to use neck, thoracic and lumbar in body parts, this list could include mid, right, left, bilateral)
Injury type
Scale from 1 to 10
Type of treatment
Exacerbating factors
Alleviating factors
Associated symptoms

yes/no and boolean yes/no are already in the current distribution, however, I add N/A to the boolean list. Say for example you are seeing a patient for the first time, some questions in the form may not be applicable.

The lists that you create will depend on the data that you are interested in tracking. Once the lists are created, work on the LBF can begin.


Sample LBFPainhx:

LBFPainhx-rendered1.png
LBFPainhx-rendered2.png


Four column view of a form

This image is included to help you visualize the columns in a form, you may design your form to be a 4 column form as this image, or to be a 6 column form, or whatever you choose. The OpenEMR default is a 4 column form.

4columns.png

Alphabetic list (as of v6.1.0):

Data type Size List Backup List
Billing codes
checkboxes number of sub-columns boxes are arranged into X
checkboxes with text field's width in the form X
exam results field's width in the form X
facilities(v4.1.1)
image canvas
insurances
lab results(v6.0.0.4)
lifestyle status(v4.0.0)
list box X X
list box with add(v3.0.0) X X
list box with comment(v6.1.0) X X
this box with search(v6.0.0) X X
multi-search facilities(v6.0.0) X X
multi-select provider(v6.0.0) X X
multiple select list(v4.2.0) X X
Nation notes(v4.1.0) X
organizations
patients(v6.1.0)
patient signature(v5.2.1)
patient allergies
pharmacies
previous names(v6.1.0)
provider's
providers NPI
race/ethnicity(v4.0.0)
radio buttons(v3.2.0) number of sub-columns buttons are arranged into X
smoking status(v4.0.0)
squads
static text(v4.0.0)
text state
text area "cols" value
text box field's width in the form
text box list field's width in the form
user signature(v5.2.1)
visit categories

Please note that if the version of OpenEMR is not in parenthesis, the data type may predate v2.7.0

Resources

Layout based visit forms
Sample LBF
LBF for ophthalmology