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Re: [Gnumed-devel] Systems of Recording Medical information


From: Karsten Hilbert
Subject: Re: [Gnumed-devel] Systems of Recording Medical information
Date: Mon, 29 Jun 2009 23:25:02 +0200
User-agent: Mutt/1.5.18 (2008-05-17)

On Mon, Jun 29, 2009 at 05:31:42PM -0300, Rogerio Luz Coelho wrote:

> Well, I was tought the Present Complaint system

Believe it or not, I haven't been taught ANY system at med
school !  I pretty much partially found (SOAP) and partially
re-invented (issue, episode, encounter) it myself ...

I was lucky just about early enough to find literature that
channelled my re-"inventions" onto the right track to not
get too far with making my own mistakes and stick with them :-)

The first time I came into contact with SOAP was during in
internship in Chiang Mai, Thailand (!) -- I was hooked
immediately. At the time I was already involved with GNUmed...

> 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,

Not only can it be used but a more specialised UI (or
plugin) can take advantage of the following facts:

- there can be more than one sOap row per encounter per episode

- such sOap rows can be tagged to make them distinguishable
  (one could tag one sOap row musculoscelatal and another one
   neurological)

> 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.

Nice !   Care to share that with the community ?

> This is just a way to make GNUmed relate more closely to my practice,

It's also how I envisioned this to be used.

> 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 ;)

I fully agree !

Karsten
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