We recently started working with a mental health organisation. At their place their clients are in the premises for much longer duration (in months). They also have multiple departments which looks after different aspects of the health and well-being of the client. Each client is assigned to one provider (lets call them client-owner), who takes complete ownership of the client when they are the hospital.
Sometimes the client-owner wants to refer them to some departments for checkup or care (like Psychiatrist, General medicine). This information needs to be captured in the system, because in their current paper world it is hard to keep track of these referrals and they tend to get missed out. So my question is how should these referrals be modelled. So far we have been using disposition in other places for this. That is, the doctor sets the disposition as to be admitted on the patient and it shows up in the IPD nurses list. But this seems inadequate because we can have only one in the encounter. I feel that this kind of scenario can happen in a general hospital too. Also, given than one wants to track what happens to these internal referrals, wouldn’t they be better modelled as orders - since they have fulfilment observations associated to them.
Generally you’d want to record something as an order when at least one of
these is true:
you want to it to trigger some action
you want to track the request from being active/open to fulfilled/closed
I would distinguish between a Referral (“I want X specialty to see the
patient, and send me back their thoughts”) vs ADT (“I want the patient to
be admitted/transferred to X type of ward”).
Referrals definitely make sense as orders.
Admission/Transfer/Discharge could be done as orders also. The current
model of recording a disposition obs is fine as far as answering “where do
I think the patient is gong next after this encounter” and I’d lean towards
leaving these as disposition obs for general compatibility, unless you need
to change it.
Disposition answers “where should this patient go next?” Disposition and follow up (e.g., “return to clinic in 2 months” or “admit to hospital”) will most likely become attributes of the encounter in the future. Using obs is a reasonable workaround for now.
Referrals (also called consults) are requests (i.e., ordesr) for the patient to be seen by another service. These are orders just like drugs and tests. For example, I might evaluate a patient for shoulder pain and a rash, order a drug to treat the rash, order an x-ray to evaluate the shoulder pain, and write to referral orders (one to dermatology to follow up the rash and another to physical therapy to evaluate & treat the shoulder pain).
This has nothing to do with this question itself, but really a small design issue for Bahmni. The disposition is a tab by itself in Clinical because it doesn’t fit anywhere else, does very little, so it doesn’t seems like it has earned a tab for itself. So I was trying to be done with Disposition while we support referral :-).