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CSIRO Primary Care Core Data Project

Please consider these data items and how they appear and are used in your current system(s)

1.       Reason for Encounter /Reason for Visit
2.       Condition List/Problem History
3.       Prescriptions
4.       Current Medication List
5.       Adverse Reactions
1.How do you currently record these in the patient record?  Do you search and select items or do you free text?
Search and Select from a list
Free text
Reason for Encounter /Reason for Visit
Condition List/Problem History - Name
Condition List/Problem History - Date diagnosed
Condition List/Problem History - Status
Prescription - Drug name
Prescription - Dosage Instructions
Prescription - Route
Prescription - Repeats
Prescription - Reason
Current Medication - Medication Name
Current Medication - Medication Dose, route and timing
Current Medication - Instructions
Current Medication - Reason
Current Medication - Period
Adverse Reactions  - Substance
Adverse Reaction - criticality
Adverse Reaction - verification status
Adverse Reaction - Manifestation 
Adverse Reaction - Manifestation - severity
Advers Reaction - Clinical Status
Procedure - Name
Procedure - performed Date/Time
2.What is missing that results in you choosing free text
3.Can you see any issues with recording this information if free text was not available?
Yes
No
Reason for Encounter /Reason for Visit
Condition List/Problem History - Name
Condition List/Problem History - Date diagnosed
Condition List/Problem History - Status
Prescription - Drug name
Prescription - Dosage Instructions
Prescription - Route
Prescription - Repeats
Prescription - Reason
Current Medication - Medication Name
Current Medication - Dose, Route and Timing
Current Medication - Instructions
Current Medication - Reason
Current Medication - Period
Adverse Reactions  - Substance
Adverse Reaction - criticality
Adverse Reaction - verification status
Adverse Reaction - Manifestation 
Adverse Reaction - Manifestation - severity
Advers Reaction - Clinical Status
Procedure - Name
Procedure - performed Date/Time