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

[Karsten Hilbert]

Richard,

> 1) The presentation may be from the existing active/inactive problem 
> list eg Hypertension,
> hence in the medical records one needs to be able to select the problem 
> from this list, and add SOAP notes regarding it
Sure, but that's an implementation issue, eg front-desk stuff
selecting an active problem thereby pre-activating an episode
and opening a new encounter on it adding a new RFE. Or myself
doing that during the encounter.

> (even if some components 
> of SOAP may not be filled in), so that a later time all records 
> pertinant to that problem may be viewed sequentially, even where they 
> were only a part of a multi-problem encounter.
Absolutely. The proof that that is possible with GnuMed today
in in Carlos' exporter.

> 2) The presentation is a new well defined symptom/symptom group with a 
> defined diagnosis at the end (eg URTI) which will not be a significant 
> problem long term.
Will likely result in a one or two-encounter episode of
"uncomplicated URTI" for which an RFE is entered ("pain on
swallowing") but no previous episode is activated (or a new
one generated).

> 3) The presentation is well defined and will be a significant problem 
> long term eg MI/IHD and the problem is added to the long term list of 
> problems
To which the most recent AOE of the pertinent episode "MI" is
added virtue of it belonging to an active encounter, perhaps
staying on it due to it being labelled manually or
automatically as permanent.

> 4) The presentation is undifferentiated and no diagnosis is reached at 
> end of the consultation
>    - This one is should probably still be recorded in SOAP/extended 
> text notes/ but the difficulty is how to tag it in the records.
That is why the AOE is not the same as a diagnosis. It can be
but only if it is one :-) and hence has additional data in
additional tables, eg. a link to a code or some such.

> If may 
> later have a diagnosis attatched to it, eg ill defined upper abdominal 
> pains may later be diganosed as gall stones/peptic ulcer etc.
Which would show up in the progression of AOEs over time.

> 5) Some consultations as simple narratives eg phone consultation 
> with/from patient without  an attatched problem but still have to be 
> recorded.
They may belong to an existing episode, eg "Doctor I need a BP
pill refill" or constitute a new one, eg. "Doctor, I am
leaving for Brazil tomorrow, do I need any shots ?" (gotta
love that one ;-)  They will still be groupable by SOAP.

> This fits the editing area concept brilliantly as intelligence can be 
> linked to each of the lines to supply an appropriate list of pop up 
> words, matching the users input, but contexturally according to the line 
> one is on.
Absolutely !

> ie the AOE should be a tag linked to the whole of the particular 
> consultation episode

> and one should be able to review sequential AOE's like one would review a 
> flow diagram.
Exactly !

> As I mentioned in a previous post, I think we could incorporate all the 
> benefits of the defined editing area into a smart text editor by 
It sounds very useful and is actually quite similar to what we
got here. Our software often operates on the concept of lines
that are labelled by soap, adding a line you can define any of
soap. Mostly you can move freely with the cursor and the soap
context changes on the fly.

> Coding such an editor is not that hard.
Not sure. I wouldn't want to do it but then I don't like GUI
coding.

> Anyway, I'm not sure if this adds anything to the discuss
it does

Karsten
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