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Re: [Gnumed-devel] Data entry-soap stuff - I tried it all day

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] Data entry-soap stuff - I tried it all day
Date: Tue, 16 Nov 2004 10:48:58 +0100
User-agent: Mutt/

> >This is how I would propose to handle *coding* part of the
> >narrative. Select some part of it, invoke code browser to
> >attach codes, store selected codes in a holding dict, mark
> >coded string in the narrative, eg.:
> If in the Physical we will allocate / parse abnormal findings into 
> one (or more) episodes, what do we do with the "normal/negative" 
> findings, do we tag these also to whichever episode they best related 
Seems obvious to me.

> to, or should we put them in a "Normal Physical" episode?

When I listen to the lungs but find them normal I either
decide that I don't record that fact or I decide to record it.
What I then record is that I found that in this encounter for
the episode I was acting on the lungs were found to be WNL.

In outpatient care I seem to encounter quite few normal
observations that weren't done with a specific agenda in mind.
This is different from Weed's original "data base" concept, BTW.

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