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How to create "observations" for my Elec Med Record (EMR)

Question asked by dsimonson on Nov 11, 2015
Latest reply on Nov 11, 2015 by dsimonson

I'm back at work on my anesthesia Electronic Medical Record (EMR).  My next task is to figure out how to model and track the numerous "observations" that the anesthetist makes during the actual anesthetic. 

 

All observations have one characteristic in common: they are made at a certain time.  Other than that, they can be very different.  Here are some examples.  In each of these, I want a time and then:

 

Blood pressure

Heart Rate

Respirations

 

Medication - name, amount, unit of measure

Blood - type, amount

Urine - amount

Fluids - type, amount

 

Ventilator settings - peak pressure, volume, rate

 

etc.

 

I am thinking that I should have one table of observations, with the foreign key being the anesthetic primary key.  I would then have a field denoting the type of observation (an abbreviation or something for each of the items in the list above), and a zillion fields to account for all of the variations I am recording.  Here are some examples of records and fields:

 

Time Type Systolic Diastolic Heart Rate Med Name Amount Unit

12:01 Med                                              diazepam      2           mg

12:02 VS      120      80                80

 

(VS stands for “Vital Signs”, which would be the type of Observation).

 

The goal of all this is to allow me to display on the “record” a portal from the anesthetic into the observations table. 

 

My question: does this sound like a good plan?  My portal is going to contain too many fields to show all of them, so I am thinking I will need separate portals for the various types of observations.  I will have a portal on the layout showing meds, one showing vital signs, one for fluids, etc. 

 

What do you all think?  Thanks for any advice!

 

Dan

Outcomes