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Re: [Gnumed-devel] Data entry-soap stuff - I tried it all day
From: |
Karsten Hilbert |
Subject: |
Re: [Gnumed-devel] Data entry-soap stuff - I tried it all day |
Date: |
Tue, 16 Nov 2004 10:54:14 +0100 |
User-agent: |
Mutt/1.3.22.1i |
> BTW where in a SOAP note does one capture that any test results got
> any consideration as part of a patient assessment? They *are*
> considered "Objective" results, but they originated outside the
> current SOAP encounter. Do we thread any such "reflection" into our
> Assessment?
In-house tests for which I expect to have results available
within the same encounter I would record under Objective w/o
recording the *intent* to have them. For off-site lab which
will take a while the intent would be recorded as ordered under
Plan. The German importer will attach incoming results to the
episode pertinent to the recorded request/ordering of said
results. They also get attached to the originating encounter.
Karsten
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