Journalnotes

A number of actions performed in SFM are information that should be included in the "Cllnical Note" (Løpende journal). 

Changes that are considered journal-worthy are stored in JournalNotes in SFM, and can be transferred to the EPJ so that these can be automatically recorded in the EPJs Clinical Note.

A Patient has a consultation with a Doctor.

The EPJ controls how long such a consultation/period lasts.

 

1) When the SFM is opened from the EPJ, the EPJ sends an ID indicating that the SFM has been opened in the context of this consultation.

2) All events that the doctor then does in the SFM are logged in a "Journalnotes" table in the SFM - in the context of this "consultation" (ID).

3) When the doctor signs (and sends) the list in the SFM, an "indication" will be sent to the EPJ that there are journal-worthy events related to the ongoing consultation, and will be a signal to the EPJ to request events.

4) The EPJ will then ask for and download signed events for the current consultation and record what is relevant in the Ongoing Journal.

 

Usecases that triggers events in Journalnote

Triggered Events

Doctor creates a new treatment

without Resept 

 

sign&send

Doctor creates a new treatment

with Resept

 

sign&send

Doctor renew a Resept 

 

 

sign&send

Doctor changes a treatment

with Resept

 

sign&send

Doctor seponates a treatment 

with resept

reason: dobbeltoppføring

sign&send

           
Opprettet behandling X X      
Forny resept     X    
Endret behandling       X  
Seponert behandling         X*
Sendt resept   X X X  
Sendt PLL (X) (X) (X) (X) (X)

*Can be filtered out based on reason for discontinuation (seponeringsårsak)

 

NOTE: When "someone" signs, a signal is sent to the EPJ. The EPJ does not know "who" has signed, i.e. what role - whether it is, for example, a Nurse or a Doctor.

SFM will not create events when drafts are created, only when a treatment is created by a doctor, or a draft is approved by a doctor or doublesigned ny a nurse (not a draft anymore). 

Triggered Events

Assistant (medhjelper) creates, renews, changes or seponates a treatment

with Resept

sign lokalt

Assistant (medhjelper) creates, renews, changes or seponates a treatment

without Resept

sign lokalt

Doctor approves a draft

 

 

 

sign&send

Nurse double-signs

 

 

 

sign draft

Doctor rejects a draft

           
Opprettet behandling X* X* X X  
Forny resept X* X* X X  
Endret behandling X* X* X X  
Seponert behandling X* X* X X  
Sendt resept     (X)    
Sendt PLL     (X)    

*The red Xs creates events today, but will soon be removed, https://thula.atlassian.net/browse/SFM-22650

 

Triggered Events

Doctor creates, renews, changes or seponates a treatment

with Resept

Doctor regrets creating, renewing, changing, seponating the treatment

(only non-signed events can be regretted)*

Doctor creates, renews, changes or seponates a treatment

 

sign&send

Doctor deletes creating, renewing, changing, seponating the treatment

Lege bekrefter importert behandling i bruk
           
Opprettet behandling X X X    
Forny resept X X X    
Endret behandling X X X    
Seponert behandling X X X    
Sendt resept     X    
Bekreftet behandling         X
Slettet ordinasjon       X  
Sendt PLL     X X X

*Note that unsigned events may be regretted, and regretted events will not be returned when retrieving events after the time of the regret-action. If the EPJ retrieves events before they are signed and record these events in the Journal, there is a risk of recording events that will be regretted. We therefore recommend not recording events to the journal, before the signal of signed Lib.

 

The recommendations presented in this table is prepared based on discussions in SFMs medical advisory group, january 2025.

Note that it may be relevant to extend the information from JournalNote with additional information from the related treatments (retrived by Lib-list) - to be stored in the Clinical Note. 

Event
Triggered
Recommendation for recordings in Clinical Note
 

 

 

Opprettet behandling

When treatment (with or without Resept) is created in SFM

Recommended to be recorded after signing

Forny resept

When a Resept is renewed (pure renewal, without change)

 

Recommended to be recorded after signing

(This may be a renewal of an entry made outside the organisation, it is desirable that this is recorded in the Medical Note)

Endret behandling

When a treatment (with or without Resept) is changed

Recommended to be recorded after signing

Seponert behandling

When a treatment is seponated

 

 

Recommended to be recorded after signing

Reason and Note should be included in the Clinical Note. 

It is possible to filter out reasons for discontinuation that are not relevant (e.g. dobbeltoppføring).

Sendt resept

When a Resept (M1) has been sent to RF

Recommended to be recorded after signing

May be merged with the actions above, if the ReseptId is the same. I.e "Endret og sendt resept" on one line. 

Bekreftet behandling

When a treatment is included in LIB. 

Is triggered both when the treatment is actively included, or when it is "automatically" included when i.e signing the list. 

NOT recommended to be recorded in the Medical Note for GP offices as this will generate a large number of entries. 

Must be considered for PLO or for other organisational types. 

Slettet ordinasjon

When the treatment is actively deleted

Recommended to be recorded after signing

Gjennomført

legemiddelgjennomgang

When the date of completed drug review is stored in SFM

Recommended to be recorded after signing

Opprettet CAVE

When a new CAVE is created in SFM by a user (regardless of whether it is synchronized to Kritisk Info in Kjernejournal or not).

Recommended to be recorded after signing

Endret CAVE

When a CAVE is changed in SFM by a user (regardless of whether it is synchronized to Kritisk Info in Kjernejournal or not).

Recommended to be recorded after signing

Avkreftet CAVE

NWhen a CAVE is "avkreftet" in SFM by a user (regardless of whether it is synchronized to Kritisk Info in Kjernejournal or not).

Recommended to be recorded after signing

Søknad sendt til Helfo

When an application is returned by a new lookup to  Helfos vedtaksspørring, that was not returned by the first lookup.

Derived and assumed, since the application portal is outside of SFM.

Recommended to be recorded after signing

Registrert multidoseansvar

When M27.1 is sent to RF with Registreringsstatus "Registrering"

Recommended to be recorded after signing
Avregistrert multidoseansvar When M27.1 is sent to RF with Registreringsstatus "Avregistrering" Recommended to be recorded after signing
Opprettet første PLL

When the first PLL (M25.1) is sent to RF for a patient, after using the "Opprett PLL" functionality in SFM

Recommended to be recorded after signing
Sendt PLL

When PLL (M25.1) is sent to RF

NOT recommended to be recorded in the Clinical Note