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Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2
Date: Wed, 24 Nov 2004 12:08:46 +0100
User-agent: Mutt/

> Currently, to capture Past History items which of these options have 
> support:
> 1 directly create clin_health_issues unlinked to any episode soap row
Yes. I would use that to record most issues.

> 2 input into a Soap_row, and attach the enclosing episode to an inserted 
> health_issue
This is possible. May be useful for a catch-the-rest health
issue, eg "more past history" or something.

> 3 input into a soAp row, and attach a diagnosis but optionally not to an issue
Possible technically, must be attached to an episode,
however. After which it'll show up in the composite "problem
list" view. The diagnosis does not currently influence where
the thing is seen, though, therefor 3 and 4 are actually
identical. Linking a diagnosis entry to a soAp row will simply
increase its level of certainty and allow for (structured)
definition of attributes of a diagnosis (localisation, etc).

> 4 input into a soap row without attaching to issue or diagnosis (clearly weak)
Same as 3, actually.

> My issues/comments:
> 1 if directly-created, how do we later know how it got there i.e. 
> based on what source of information?
By appropriate naming ?  eg. "NIDDM (pat report)" vs. "CIHK
NYHA II (discharge 2003)". Surely weak, but possible. Or,
better yet, attach an episode and a Soap or sOap row to
capture that 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,
Correct. But not a problem, technically.

> 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
Correct. Where's the problem ?

> 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?
Depends on what *you* think of it as a clinician...

> 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
Again, you can attach any number of arbitrarily created tags
to any clin_narrative item. It may indeed be useful to
pre-create a number of "well-established" tags.

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