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 | |||
Forny resept | X | X | |||
Endret behandling | X | X | |||
Seponert behandling | 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 | |||
Forny resept | X | X | |||
Endret behandling | X | X | |||
Seponert behandling | 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.
Triggers for events, and recommended recordings in Clinical Note
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 |