Re: [Gnumed-devel] GNUMed SOAP vs SOAPless progress notes

[Busser, Jim]

On 2011-11-16, at 1:36 AM, Karsten Hilbert wrote:

>> Could you just make the Note plugin with the the S in view and save it as
>> a S in the backend ?

Here is an example of the problem that I am having to decide inside which SOAP 
category to place information.

Suppose I manage to access external records of a patient from which to prepare 
a summary. I determine that

During their operation, where they received about 2L of IV fluid, they were 
observed to obstruct their airway and quickly drop their O2 saturation to 40% 
but that on being turned from prone to supine and suctioned, they improved to 
90% and, within another few minutes, 98% (on supplemental oxygen) and that 
their blood pressure and pulse were normal throughout. They were briefly 
converted from conscious sedation to general anaesthesia (intubated) but 
improved quickly and were later able to be extubated in the ICU.

Part of what makes it hard is that it is not a patient complaint but rather an 
abstracting of a record of an event. The other part that is hard is that it is 
subjective (in that *I* made no measurements) but it is objective (in terms of 
a description of what is documented and which included second-hand 
measurements).

Even if such an entry (as the above) would not get assigned any among

        SOAP

part of me continues to think there is value to distinguish it from NULL e.g. 
administrative or daemon or clerical (desk staff) entries. I am thinking that

        U

for unspecified might be arguable as entirely reasonable. This 'U' could also 
remain invisible until such time as it was desired (in searches or with 
placeholder parameters) to distinguish

        S
        O
        A
        P

which may in some cases have useful granularity or focus, from the U which may 
warrant to be clinically included or excluded (at the same time as we may wish 
to keep NULLs out of scope for particular purposes).

??

-- Jim