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Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2
From: |
J Busser |
Subject: |
Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2 |
Date: |
Tue, 23 Nov 2004 02:02:44 -0800 |
I too suspect we cannot further deconstruct or debate the record
design effectively until we ascertain perhaps working through some
examples whether (and how) the current ideas can deliver us what we
want / need.
This email is to introduce some questions around how to handle a case
that I offer in the accompanying (separate) email. I am interested to
see what people prefer to do with "past history" when a patient
enters a (GP) practice, and/or is referred to a general specialist
who cares to stay cognizant of patients' multiple issues.
Currently, to capture Past History items which of these options have support:
1 directly create clin_health_issues unlinked to any episode soap row
2 input into a Soap_row, and attach the enclosing episode to an
inserted health_issue
3 input into a soAp row, and attach a diagnosis but optionally not to an issue
4 input into a soap row without attaching to issue or diagnosis (clearly weak)
My issues/comments:
1 if directly-created, how do we later know how it got there i.e.
based on what source of information?
2 if input into a Soap row (based on patient or proxy's oral
account), we then need a separate Soap row (and separate episode) for
each item in the past history , also if we wish the health_issue to
take its name from the episode or to be able to attach one or more
diagnoses we would in addition need a soAp row for every past history
item that we wish to capture
2 also, when the source is not the patient's oral account, but is
instead from our paper chart, or from correspondence received on
paper and possibly scanned, or received electronically, is this
"o"bjective?
3 is maybe suited to when we see no obvious need to "care for" a Past
History item
4 is only if we have some alternate mechanism to tag and later
subselect certain types of history as Syan was asking, for example I
am not sure how we expect to draw out stored info on risk behaviours
(EtOH, tobacco, sex & other so-called Social History), likewise
Family History if these are all supposed to be entered into
clin_narrative
- Re: [Gnumed-devel] Re: clin_health_issue - some thoughts, (continued)
- [Gnumed-devel] The 1,2,3's of SOAP for multiple problems, Richard Terry, 2004/11/21
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems, Karsten Hilbert, 2004/11/22
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2, Richard Terry, 2004/11/22
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2, Carlos Moro, 2004/11/22
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2, Karsten Hilbert, 2004/11/23
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2,
J Busser <=
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2, catmat, 2004/11/23
- [Gnumed-devel] Past History Comments (was 1.2.3.....), Richard Terry, 2004/11/23
- Re: [Gnumed-devel] Past History Comments (was 1.2.3.....), Karsten Hilbert, 2004/11/24
- Re: [Gnumed-devel] Past History Comments (was 1.2.3.....), catmat, 2004/11/24
- Re: [Gnumed-devel] Past History Comments (was 1.2.3.....), Karsten Hilbert, 2004/11/24
- Re: [Gnumed-devel] Past History Comments (was 1.2.3.....), J Busser, 2004/11/24
- Re: [Gnumed-devel] Past History Comments (was 1.2.3.....), Karsten Hilbert, 2004/11/24
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2, Karsten Hilbert, 2004/11/24
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2, J Busser, 2004/11/24
- Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2, Karsten Hilbert, 2004/11/24