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Re: [Gnumed-devel] need assessment from fellow clinicians


From: James Busser
Subject: Re: [Gnumed-devel] need assessment from fellow clinicians
Date: Tue, 29 Jun 2004 23:15:18 -0700
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Quoting Richard Terry <address@hidden>:

How do you handle multiple RFEs within a single visit /encounter? Do you SOAP 
each 
of them or, in the same way as I deal with hospital inpatients, do you ever 
combine 
all symptoms onto "S", all physical exam into "O" but then, depending on the 
problem(s), combine some and/or split others into separate "AP"s.

> I also like the concept of Beratungsergebnis or Assessment of Encounter.
> I call this a 'summary of the consultation", and it may go something like
> 
> Abdominal pains ?diagnosis, if doesn't settle > review or 
> Abdominal pains ?gall stones > abdominal u/s review after
> 
> Or Leg swelling > probably DVT > doppler > review today etc

I also like this concept, though it draws from the A&P of SOAP and I am fuzzy 
on the 
distinction. Is it meant to provide an abstraction, when an encounter contains 
multiple RFEs, each of which *might* have a separate SOAP (or, at least, 
separate AP  
components?)





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