These “doctor’s notes” or “sick leave” are the attestations we do for a patient when they’re ill and they need a proof of that for work and/or insurance. The contents will differ greatly in different countries, but the ones I describe here are similar to the Swedish ones1.
When writing a sick leave note, the history part is already present in the medical record in most cases, while the other fields can usually be filled in in a standard manner, since they’re more or less a description of the illness such as can be found in any medical textbook. The only reason we have to describe the illness at all is since the recipient isn’t a medical professional2.
The first step is to identify the illness or problem we’re writing a note for. Since we already have the “contact type” or “problem” in Q.E.D., we show a very limited set of codes to the user, namely the codes that have been used before by the user or by others for the same contact type. This the system learns as it goes along.
For the field “history of current illness”, we can usually simply copy the history we already entered in the medical record notes. Sometimes we have to edit them somewhat to remove irrelevant other items.
The “impact on abilities” field is meant to describe to the recipient what effect the given pathology has on the patient’s abilities in general. Since this is almost entirely determined by the diagnosis with relatively little variations between individuals, there will not be too many learned formulations in the list. If the user changes a description, another variant is added to the list for the future. (As you can see, in countries where the recipient is a medical professional, this field may not even be used at all.)
The performance limitations are intended to describe what restricts the patients in the performance of his or her actual work role due to the present illness. Q.E.D. will memorize and present formulations from earlier not only for the same contact type, but also taking into consideration the actual professional role the patient has. In other words, if a patient has back pain, this description will probably differ between an accountant and an electrician.
- I’m only showing the first page of the Swedish form, but that’s enough to describe the general principle. On the second page you’d find things like date interval, prognosis, and so on.
- In Sweden, these notes are read and classified by civil servants. In other countries where doctors receive them, most of the fields we have are unnecessary.