Re: [Gnumed-devel] The 1,2,3's of SOAP for multiple problems-2

[catmat]

J Busser wrote:

> I too suspect we cannot further deconstruct or debate the record 
> design effectively until we ascertain perhaps working through some 
> examples whether (and how) the current ideas can deliver us what we 
> want / need.
>
> This email is to introduce some questions around how to handle a case 
> that I offer in the accompanying (separate) email. I am interested to 
> see what people prefer to do with "past history" when a patient enters 
> a (GP) practice, and/or is referred to a general specialist who cares 
> to stay cognizant of patients' multiple issues.
>
> Currently, to capture Past History items which of these options have 
> support:
>
> 1 directly create clin_health_issues unlinked to any episode soap row
> 2 input into a Soap_row, and attach the enclosing episode to an 
> inserted health_issue
> 3 input into a soAp row, and attach a diagnosis but optionally not to 
> an issue
> 4 input into a soap row without attaching to issue or diagnosis 
> (clearly weak)
>
> My issues/comments:
> 1 if directly-created, how do we later know how it got there i.e. 
> based on what source of information?
> 2 if input into a Soap row (based on patient or proxy's oral account), 
> we then need a separate Soap row (and separate episode) for each item 
> in the past history ,  also if we wish the health_issue to take its 
> name from the episode or to be able to attach one or more diagnoses we 
> would in addition need a soAp row for every past history item that we 
> wish to capture
> 2 also, when the source is not the patient's oral account, but is 
> instead from our paper chart, or from correspondence received on paper 
> and possibly scanned, or received electronically, is this "o"bjective?

this source stuff is not available in the packages I've used , but its a 
much better reflection / documentation  if it is captured
about how  we come about with clinical conclusions.

> 3 is maybe suited to when we see no obvious need to "care for" a Past 
> History item
> 4 is only if we have some alternate mechanism to tag and later 
> subselect certain types of history as Syan was asking, for example I 
> am not sure how we expect to draw out stored info on risk behaviours 
> (EtOH, tobacco, sex & other so-called Social History), likewise Family 
> History if these are all supposed to be entered into clin_narrative
>
>
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