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

[Richard Terry]

James Busser wrote:

> 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, do you ever combine 
> all symptoms onto "S", all physical exam into "O" but then, depending on the 
> problem(s), combine some and/or split others into separate "AP"s.
>
>  
I think they need to be individually soaped (I do this in my notes at work)

> > 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
> >
> > Or Leg swelling > probably DVT > doppler > review today etc
> >    
>
> I also like this concept, though it draws from the A&P of SOAP and I am fuzzy on the 
> distinction. Is it meant to provide an abstraction, when an encounter contains 
> multiple RFEs, each of which *might* have a separate SOAP (or, at least, separate AP  
> components?)
>
>
>