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[Gnumed-devel] Data entry-soap stuff - I tried it all day in consultatio

From: Richard Terry
Subject: [Gnumed-devel] Data entry-soap stuff - I tried it all day in consultations
Date: Thu, 11 Nov 2004 19:36:03 +1100
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I spent today using the editor to enter all my consultations, some 30 
of them, telling the patients I was testing 'someones' concept of data entry.

Consulations were many and varied, ranging from simple I want a script for 
panamax 'Anything else', no doc, just that, to severe agitated depression, 
asthma, iritis - ie the usual mix of things we see everyday.

It soon became apparent to me that the SOAP concept just will not work at all 
and I will expand on that in a minute. I don;t mean  the concept of the SOAP 
style editor which Ian is kindly writing for us - it is brilliant (of course 
my concept!!!!), and getting  better every day, but the concept of SOAP 
itself for separating threads in data entry, I will justify this statement 
below. I can remember the debates about this on the list, but must admit I 
didn't involve myself a great deal in this. 

As the day went by I started to find that the way patients presented 
themselves, what I had to take as history, what I found, how I assessed, and 
what I did, just would not fit easily into the SOAP system. Also as we all 
know most of these patients come in with multiple complaints and it is simply 
not easy/quick to split off all the threads into different soap notes. They 
start one thing - minutes later change to another, then revert to the first 
again etc. We all know what too well.

I kept modifying the editor as the day wore on and I enclose the resultant 
png's for your perusal. Note the list under the SOAP editor which I think Ian 
has just put the Assessment column. What became very clear to me is that it 
will not be possible (and see comments below) to sub-split all problems into 
individual soap notes and still have a workable system.

I ended up late in the day ringing up Malcolm Ireland. Some of you will 
remember that he is a)Practicing GP b) computing degree c)Long term member of 
the discipline of general practice at the Newcastle University d)Many years 
the clinical IT manager for the Hunter division of General Practice and e) 
Has a  Long term interest in and research of computerised medical records. He 
has presented many many research papers over the last 15 years both in 
Australia and Overseas. Additionally he is currently sitting on state health 
dept committee in Sydney who are working with the medical software industry 
in australia, looking at what is possible, and how to co-ordinate pulling 
medical records from various sources into a single medical record (ie just 
like the gnuMed distributed server concept). Malcom has worked extensively in 
general practice IT implementing software and medical records, and uses I 
think MedTech as a paperless solution. I.e he reallly knows what he is 
talking about. If you like, and have any particular questions to fire at him 
I'm sure I could persuade him to reply and expand.

His opinion and comments were as follows. SOAP has been extensively researched 
and seems to have been discarded as a data entry system, as it does not work 
in practice. He also acknowledged just what I found today - that the only 
thing that works is to enter all the various problems into the same record of 
the consultation.

By mid afternoon, I had found the headings:

Patient Request
History Taken
Clinical Findings

Worked well. (I personally would also had a Summary of entire consultation)

When I told him what I had come up with  (see the pngs) through practical 
iteration he had quite a chuckle and commented ( and I hadn't realised), that 
the system that worked the best, was exactly the system we had been taught as 
students when learning clinical skills: (also remember he has taught medical 
students at uni for many many years)

Find out what the patient wants
Take the history
The clinical findings through your examination
Your Assessment
Your Plan 

I commented to him that in a large number of situations it wasn't possible to 
enter data in many of the fields for example as per this today (see the 
pngs), not atypical:

Patient Request: Can I have a script for panamax
History Taken
Clinical Findings
Plan: Script Panamax

Malcolm says that all the research on medical records has shown there are only 
two consistencies that matter in any written medical record - what the 
patient requests, and what the doctor did - not even the history in between 
ie how the doctor arrived at what he did.

In regard to how to link a particular consultation in a progress notes to a 
problem - there are many ways, and I note recent comments and debate on this.
when using paper notes, when we look back over a few pages say - trying to 
determine if the current symptoms - say abdominal pains - have been entered 
before - we tend to scan visually each consultation - this helps in addition 
to keep the information in context with other symptoms also recorded in the 
consultation. In the SOAP version below, I've added a simple combo box to 
allow the consulation to be linked to an existing problem, additionally  the 
user  should be able to (cannot here in this simple example) link multiple 
problems to the same consultation notes. If these are stored correctly, it 
should be a simple manner of pulling out all consultations which were linked 
to a particular problem and formatting them with html when you need to review 
a particular problem.

So in summary, check out the png's and I put forward this slight expansion of 
the SOAP editor as a move foreward. By the way - assuming many of you may 
have linux on your desktop - why not just try running SOAP2 and try recording 
a few consultations, and I enclose my modified SOAP2 for you to compare to. 
The gui is rough, so you will have to resize it prior to using it to make it 
look proportional, but you will get the idea. For those of you on Windows 
platforms it is also simple to download wxPython and run this code on your 
clinical desktop.

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