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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 10:54:14 +0100
User-agent: Mutt/

> BTW where in a SOAP note does one capture that any test results got 
> any consideration as part of a patient assessment? They *are* 
> considered "Objective" results, but they originated outside the 
> current SOAP encounter. Do we thread any such "reflection" into our 
> Assessment?
In-house tests for which I expect to have results available
within the same encounter I would record under Objective w/o
recording the *intent* to have them. For off-site lab which
will take a while the intent would be recorded as ordered under
Plan. The German importer will attach incoming results to the
episode pertinent to the recorded request/ordering of said
results. They also get attached to the originating encounter.

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