There are certain observation templates which should packaged by default with bahmni. These packaged observation templates can be divided into two categories.
- Disease or condition specific - Things like gynaecology, cancer, tuberculosis, etc.
- Clinical methodology based - Things like History, Examination, Discharge, etc.
The purpose for doing this is to provide a starting point for any implementation, standardise names for things like chief complaints, lifestyle (see below) in our code, reports, analysis.
Implementation
From the source control perspective this should be maintained in its own repository, may be called bahmni-clinical-content. If we decide to do this via the liquibase scripts we should define stored procs to make it easy to add/change these. Using CURL is also an option.
Specification for the templates
History
- Case summary
- History
- Examination
Complaints
- Chief complaint(s)
- Chief complaint notes
Detailed History
- Social history
- Family history
- Past medical history
- Past surgical history
- Treatment history
- Immunisation history
- Home medications
- Personal history - values {Smoking, Alcohol} (with duration) similar to chief complaint
- Occupational history
- History of present illness
Detailed physical examination
- Review of systems
-- Cardiovascular
-- Respiratory
-- Gastrointestinal
-- Genitourinary
-- Nervous
-- Cranial nerves
-- Endocrine
-- Musculoskeletal
-- Skin
- Physical examination
Vitals
- Blood pressure
- Pulse
- Temperature
- Respiratory rate
- SpO2
- Vital notes
Nutrition
- Height
- Weight
- BMI
- BMI status
- BSA
Returning patient
- No. of days passed
- New Complaints (chief complaints)
- % of improvement happened regarding old problem, each symptom wise or overall disease
- Symptoms - same/improved/worsened