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

Question Title

* 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

Question Title

* 2. What is missing that results in you choosing free text

Question Title

* 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

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