[Gnumed-devel] Patient Education and Consent (was: experimental editor, also SOAP)

[Jim Busser]

On Jul 5, 2004, at 2:25 AM, Karsten Hilbert wrote:
> > clin_note and clin_aux_note, which are the only 2 subclasses of 
> > clin_root_item that would seem to need
> clin_note has been expanded to be clin_narrative, the type of
> narrative being declared by soap_cat. clin_aux_note should be
> used sparingly for when a table *really* needs one more
> narrative field.

Education and informed consent combine patient reactions, questions, expectations, preferences (S) with (mostly) input from the doctor (pseudo-Objective), so do not cleanly fit in either S or O. If these must go into a SOAP part, would most advise to put them in A, in order to keep P more concise and action-oriented? I assume there is little appetite to expand the set of soap_cat values in clin_narrative row beyond {s,o,a,p}

Or is  clin_aux_note any better place to put education or informed consent?

One extra thought to handle the case of recommending a patient to undergo a diagnostic test or procedure which at times cannot be done immediately (sometimes has to be done elsewhere and by someone else who even though they may have a major part in consent it may be important to record one's own part in the matter). Just wondering if there is any value to somehow attach a record of [verbal] consent to the item that has to be booked (maybe even storing it with the item). Would this make it easier to assure that the consent has been obtained, and when tracing backward spare having to look through many SOAP notes? Also is there an idea how to "record" patient "written" consent into GnuMed?