[Gnumed-devel] Systems of Recording Medical information

[Rogerio Luz Coelho]

2009/6/29, Elizabeth Dodd <address@hidden>:
> On Mon, 29 Jun 2009, Karsten Hilbert wrote:
>> > - although I take "History taking" and "Observations" to be patterned
>> > after the traditional sequence of data gathering, they create or enforce
>> > sometimes artificial distinctions, as history and observations are both
>> > in reality also (alternatively) inputted via SOAP notes.
>>
>> I thought as much but wanted to hear it independently.
>
> There is a lovely essay on the actual heuristics of making a diagnosis.
> I think it is from a book published about 1978

> but since then the work has progressed
> http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1122649
> http://fampra.oxfordjournals.org/cgi/content/full/18/3/243
> http://www.bmj.com/cgi/content/full/324/7339/729
>
>
> It has nothing to do with SOAP or the older method we were supposed to use
> 30
> years ago
> presenting complaint
> history of present illness
> other health matters
> social history
> examination by "system" - cardiac and respiratory being artificially
> separated
> usw
>
>
> Anyway, I'm just putting this up because whatever record structure Gnumed
> has
> needs to be able to support any of the different ways in which we make a
> diagnosis
> Diagnosis as selecting a hypothesis
> Pattern recognition or categorisation
> Diagnosis as opinion revision
> Probability transformations
>
> and I'm not in favour of any particular means of recording
>
> --

Well, I was tought the Present Complaint system also (and it hasn't
been 30 years ;) , but in practical uses I mix both the formal Present
conplaint and SOAP systems.

The greatest problem I see for your problem (or recomendation)  is how
to have a multitude of ways to do the recording, although in GNUmed we
are (as far as I understood) limited by HOW the Database stores
information, so we do not have a Systems Review field inside the
Database, we have a sOap field that CAN be used as this, and I myself
use then a "Text Expansion" to get all the systems in that field so I
can manage them in a quick way with the patient.

This is just a way to make GNUmed relate more closely to my practice,
but I think IMHO that the SOAP is the method that gives us the most
flexibility in storing information, short of not making any divisions
on the patient's chart and storing everything as a single batch of
text (wich does not seem so grand in the long run ;)

Rogerio