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[Gnumed-devel] re: data entry-soap stuff

From: sjtan
Subject: [Gnumed-devel] re: data entry-soap stuff
Date: Fri, 12 Nov 2004 00:12:17 +1100
User-agent: Mozilla Thunderbird 0.8 (Windows/20040913)

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.
what about past history items , current medications and allergies. Then vaccinations, and recent screening items performed. And last blood pressure, last glucose, cholesterol ; most recent investigations. The non-computerized standard gp college health summary front sheet can do this with a glance, but in the most common clinical system here, there is a summary form, but it usually isn't trusted, and I find I go clicking on all the individual tabbed subsections , just to make sure no item or relevant detail is missed. Often have to go into an item e.g. past history item, opening it's edit dialog, to see if any details are entered, if the past history item is a little sketchy. A partially expanded emrBrowser tree could be like an expandable health summary sheet if properly organized. Wrt to past progress notes items, one scrollable flat past entry listing might be sufficient most of the time, but the option of filtering or even searching notes on terms/keywords could be there. Maybe have markers on the side of the vertical scrollbar, to mark where items are found in the chronology of the entire past progress notes, after a search or filter is done ( idea from eclipse editor).

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.

*stored correctly* this is a goal even our Lowest Common Denominator dominant mutant oz prescription writer pays lip service to , but I think coding/linking is regularly violated by busy gps who just want to get the notes in , the scripts printed, and the pathology ordered. It also goes against the single soap per consultation idea, - is it possible to have single soap, and proper linking to episodes of health issues , in a nice gui workflow ? Being more of an art critic than an artist, hope to see some innovative solutions from the gnumed team.

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