Recovery room discharge encounter roles

Tags: #<Tag:0x00007ff4b934c780> #<Tag:0x00007ff4b934c6b8>

Hi @akanter, @burke, @jdick, @jteich,

I would like to kindly request some sharing of your clinical knowledge for the following use case.

We are collecting data of the post-surgery recovery room discharge encounter that occurs in a hospital setup. It is a nurse participating in the encounter that records the data, and in particular (s)he records whether a green light is given or not to discharge the patient from the recovery room.

While recording whether the green light is given, (s)he also records the encounter provider that gives the green light. (Apparently this encounter provider is either the anaesthetist or the surgeon.)

In this case two encounter providers are recorded in the end:

  1. The nurse, who records the data.
  2. The clinician who gives the green light to discharge.

Because two encounter providers are recorded it is necessary to clearly identify their encounter roles and this is where I would need your help. What is the encounter role of the clinician that gives the green light to discharge? Is there a proper clinical term for this? Or am I overthinking this and basically I should just go with something as basic and simple as:

  • Unknown/default and clinician, or
  • Nurse and clinician

?

Cc @premnisha @jesplana

On first look it seems that this is a similar workflow as any other type of discharge or transfer. Just as in those scenarios, in the O.R. case I consider the person who “gave the green light” as a clinician writing an order (discharge order or transfer order). The nurse is receiving, acknowledging, administering the order.

In that scenario you have Ordering Clinician and Nurse roles.

If the clinician also sees the patient, and documents their needs, then that could be a distinct encounter.

2 Likes

Thank you for the detailed answer @jteich, that’s really helpful.