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Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2

From: catmat
Subject: Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2
Date: Wed, 24 Nov 2004 11:37:34 +1100
User-agent: Mozilla/5.0 (X11; U; Linux i686; en-US; rv:1.7.3) Gecko/20040913

J Busser wrote:

I too suspect we cannot further deconstruct or debate the record design effectively until we ascertain perhaps working through some examples whether (and how) the current ideas can deliver us what we want / need.

This email is to introduce some questions around how to handle a case that I offer in the accompanying (separate) email. I am interested to see what people prefer to do with "past history" when a patient enters a (GP) practice, and/or is referred to a general specialist who cares to stay cognizant of patients' multiple issues.

Currently, to capture Past History items which of these options have support:

1 directly create clin_health_issues unlinked to any episode soap row
2 input into a Soap_row, and attach the enclosing episode to an inserted health_issue 3 input into a soAp row, and attach a diagnosis but optionally not to an issue 4 input into a soap row without attaching to issue or diagnosis (clearly weak)

My issues/comments:
1 if directly-created, how do we later know how it got there i.e. based on what source of information? 2 if input into a Soap row (based on patient or proxy's oral account), we then need a separate Soap row (and separate episode) for each item in the past history , also if we wish the health_issue to take its name from the episode or to be able to attach one or more diagnoses we would in addition need a soAp row for every past history item that we wish to capture 2 also, when the source is not the patient's oral account, but is instead from our paper chart, or from correspondence received on paper and possibly scanned, or received electronically, is this "o"bjective?

this source stuff is not available in the packages I've used , but its a much better reflection / documentation if it is captured
about how  we come about with clinical conclusions.

3 is maybe suited to when we see no obvious need to "care for" a Past History item 4 is only if we have some alternate mechanism to tag and later subselect certain types of history as Syan was asking, for example I am not sure how we expect to draw out stored info on risk behaviours (EtOH, tobacco, sex & other so-called Social History), likewise Family History if these are all supposed to be entered into clin_narrative

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