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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: Wed, 17 Nov 2004 19:06:42 +0100
User-agent: Mutt/

> yes and as I think about it, when reviewing results via the journal 
> and reminding oneself of why the tests were done
Which is recorded in two places: 1) the active problem the
request is attached to tells us what we did the tests for. And
then there's a progress notes line attached to the requests in
which one would enter a quick note during ordering (eg. "r/o
gout" or something).

, it would be good to 
> be able to "flip" to the clinical record of the patient to whom a 
> result belongs, enter "chart review" mode

> and, if appropriate, record 
> any revision to the Assessment or Plan in a soAP note. Would this be 
> the same encounter as the "chart review" or would this be "read only"?
The originating encounter would be read-only for all but some
very important reasons (eg. fix relevant recording error to
not confuse later users). The "revision" of Plan/Assessment is
actually a re-Assessment in a new encounter (w or w/o the
patient present). The user, however, could always opt to
modify/amend the original encounter forcefully - which isn't
the intent but can be done technically. The audit trail is
preserved in any case.

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