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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 |
User-agent: |
Internet Messaging Program (IMP) 3.1-cvs |
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?)