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Re: [Gnumed-devel] need assessment from fellow clinicians

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] need assessment from fellow clinicians
Date: Wed, 30 Jun 2004 15:40:54 +0200
User-agent: Mutt/

> Quoting Richard Terry <address@hidden>:
> How do you handle multiple RFEs within a single visit /encounter? Do you SOAP 
> each 
> of them or, in the same way as I deal with hospital inpatients,
What I tend to do:

If they are cleanly separated episodes I completely separate
them into separate SOAPs.

If they belong to the same episode but have distinct qualities
that need to be dealt with pointedly I usually just number
them and repeat that numbering in each of the SOAP parts.

> > I also like the concept of Beratungsergebnis or Assessment of Encounter.
> > I call this a 'summary of the consultation", and it may go something like
> > 
> > Abdominal pains ?diagnosis, if doesn't settle > review or 
> > Abdominal pains ?gall stones > abdominal u/s review after
I split those into A and P almost always. However, they are on
consecutive lines in the chart, so, hey :-)

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