Pain History LBF

Introduction

Layout-based forms (LBFs) are quite versatile. If you are not familiar with LBFs, check out this page.

Definitions

First some definitions. We all need to be on the same page. What may be a form to a programer, may mean something totally different to a provider. Terminology clarification:

Form:

"A form is a user interface element within a website or software application that allows you to enter and submit data. It contains one or more fields and an action button, such as Save or Submit." techterms.com. Hence, a form, is not a progress note. A form may be used to gather information from the patient, or from the provider in order to be entered into the database.

Progress note:

"Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care." wikipaedia. Hence, a progress note may be entered into the record via the use of a form.

Report

In the administrative term versus the clinical term, the word report may mean several different things. According to Oxford languages a report is "an account given of a particular matter, especially in the form of an official document, after thorough investigation or consideration by an appointed person or body."

In healthcare, in order for a specialist to get reimbursed at a higher level, he/she must have a referral from a referring physician, and must send back a report within a specific amount of time. Hence, a report is a document that is generated after an encounter/visit in order to be sent back to the referring physician.

However, a report may also be custom

Custom report (as in healthcare administration):

A Custom Report is a report that you create. You pick the dimensions (City and Browser, for example) and metrics (Sessions, Pageviews, and Bounce Rate, for example) and decide how they should be displayed. You must specify at least one dimension and one metric (google analytics). Hence, this type or report can be generated in order to evaluate a specific measure, such as the visits for today, the number of patients that are indigent, or who have BCBS for example.

So, let us all speak the same language as best as possible.

Planning your LBF

Planning your LBF, refer to the pain history form below:

Observe that the form includes certain lists:

Body parts

Laterality (optional, for example, if a chiropractor addresses only the spine and wants to use neck, thoracic and lumbar in body parts, this list could include mid, right, left, bilateral)

Injury type

Scale from 1 to 10

Type of treatment

Exacerbating factors

Alleviating factors

Associated symptoms

yes/no and boolean yes/no are already in the current distribution, however, I add N/A to the boolean list. Say for example you are seeing a patient for the first time, some questions in the form may not be applicable.

The lists that you create will depend on the data that you are interested in tracking. Once the lists are created, work on the LBF can begin.

Sample LBFPainhx:

Four column view of a form

This image is included to help you visualize the columns in a form, you may design your form to be a 4 column form as this image, or to be a 6 column form, or whatever you choose. The OpenEMR default is a 4 column form.

Alphabetic list (as of v6.1.0):

Data type	Size	List	Backup List
Billing codes
checkboxes	number of sub-columns boxes are arranged into	X
checkboxes with text	field's width in the form	X
exam results	field's width in the form	X
facilities(v4.1.1)
image canvas
insurances
lab results(v6.0.0.4)
lifestyle status(v4.0.0)
list box		X	X
list box with add(v3.0.0)		X	X
list box with comment(v6.1.0)		X	X
this box with search(v6.0.0)		X	X
multi-search facilities(v6.0.0)		X	X
multi-select provider(v6.0.0)		X	X
multiple select list(v4.2.0)		X	X
Nation notes(v4.1.0)		X
organizations
patients(v6.1.0)
patient signature(v5.2.1)
patient allergies
pharmacies
previous names(v6.1.0)
provider's
providers NPI
race/ethnicity(v4.0.0)
radio buttons(v3.2.0)	number of sub-columns buttons are arranged into	X
smoking status(v4.0.0)
squads
static text(v4.0.0)
text state
text area	"cols" value
text box	field's width in the form
text box list	field's width in the form
user signature(v5.2.1)
visit categories

Please note that if the version of OpenEMR is not in parenthesis, the data type may predate v2.7.0

Resources

Layout based visit forms

Sample LBF

LBF for ophthalmology