Re: [Gnumed-devel] Systems of Recording Medical information

[Jim Busser]

I enjoyed Liz' links.

Earlier on this list, there had been some discussion of whether to  
adapt (improvise) Unattributed episodes for use as containers of  
categorical historical information that did not yet have their own  
widgets - think Family History, Risk factors

One thing I have still been wondering is where to store cumulative  
information. For example the case where each health issue inherits,  
over time, some summary information that includes the extent /  
severity of disease and future options, or the equivalent of a care  
plan for the problem. I cannot see such detail always having to be  
copied-forward into the most recent SOAP lines and therefore the most  
recent soAp and soaP lines and AOE will not contain the fullness of  
what might have been accumulated as a per-problem profile.

Some of this might be approximated by a per-problem view in which  
rows of a certain type would be filterable. Such could facilitate a  
view on *just* the Assessments, or *just* on the Plans, going back  
over many encounters. I further expect that to be able to select from  
among these rows, and to auto-concatenate the content, could enable  
an optionally-editable note to serve as a "digest" of the problem.

Past History items, at their creation, can have an associated  
"inception note" and I wonder if it is the same or similar row that  
might be usable to contain the type of information in this use case?

On 29-Jun-09, at 1:31 PM, Rogerio Luz Coelho wrote:

> 2009/6/29, Elizabeth Dodd <address@hidden>:
> > On Mon, 29 Jun 2009, Karsten Hilbert wrote:
> > > > - although I take "History taking" and "Observations" to be  
> > > > patterned
> > > > after the traditional sequence of data gathering, they create or  
> > > > enforce
> > > > sometimes artificial distinctions, as history and observations  
> > > > are both
> > > > in reality also (alternatively) inputted via SOAP notes.
> > >
> > > I thought as much but wanted to hear it independently.
> >
> > There is a lovely essay on the actual heuristics of making a  
> > diagnosis.
> > I think it is from a book published about 1978
>
> > but since then the work has progressed
> > http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1122649
> > http://fampra.oxfordjournals.org/cgi/content/full/18/3/243
> > http://www.bmj.com/cgi/content/full/324/7339/729
> >
> >
> > It has nothing to do with SOAP or the older method we were  
> > supposed to use
> > 30
> > years ago
> > presenting complaint
> > history of present illness
> > other health matters
> > social history
> > examination by "system" - cardiac and respiratory being artificially
> > separated
> > usw
> >
> >
> > Anyway, I'm just putting this up because whatever record structure  
> > Gnumed
> > has
> > needs to be able to support any of the different ways in which we  
> > make a
> > diagnosis
> > Diagnosis as selecting a hypothesis
> > Pattern recognition or categorisation
> > Diagnosis as opinion revision
> > Probability transformations
> >
> > and I'm not in favour of any particular means of recording
> >
> > --
>
> Well, I was tought the Present Complaint system also (and it hasn't
> been 30 years ;) , but in practical uses I mix both the formal Present
> conplaint and SOAP systems.
>
> The greatest problem I see for your problem (or recomendation)  is how
> to have a multitude of ways to do the recording, although in GNUmed we
> are (as far as I understood) limited by HOW the Database stores
> information, so we do not have a Systems Review field inside the
> Database, we have a sOap field that CAN be used as this, and I myself
> use then a "Text Expansion" to get all the systems in that field so I
> can manage them in a quick way with the patient.
>
> This is just a way to make GNUmed relate more closely to my practice,
> but I think IMHO that the SOAP is the method that gives us the most
> flexibility in storing information, short of not making any divisions
> on the patient's chart and storing everything as a single batch of
> text (wich does not seem so grand in the long run ;)
>
> Rogerio
>
>
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