[Gnumed-devel] Progress notes entry and patient interaction

[Jim Busser]

David Guest made a very nice post back in 2002 (still on the archives and referenced below)

Its relevance to the current GNUmed is as follows. I myself am cognizant of the distraction between being attentive to a patient telling his or her story, at the same time as I feel pressured to "split" (both my thinking i.e. "brain-parsing", and my keyboarding) of bits as they arise, or even at intervals. At a stage when I do not yet know the fullness of the information that is to come, it feels way too early to pre-allocate the information. Accordingly I can imagine working in two modes at the same time:

1) for those visit agenda items that clearly enough need to be taken care of, out those in the RFE (reason) for encounter... this way they remain in view above potentially multiple encountlets, no matter which of multiple would be active, however

2) apart from the above, build up "note text" inside the default Unattributed "S"oap row.

If any would be interested to examine the bottom of David's posting (his example), his tilde-separated bottom two lines

initial nausea on Lipitor
now settled

denote an issue easily enough ascertainable at the start of the visit or along the way and lends itself to but put into the RFE (and to have its own soaplet raised) at the first point of convenience. His *other text* is as follows:

*History*
continuing abdo pain
headaches
- frontal, mild, constant, paracetamol helps
poor sleeping
- dozes for an hour
- wakes repeatedly through the night
- will stay awake for 1-3 hours each time
-- now sleeping in separate room to wife
- tired in morning
- slight improvement in late afternoon
edgy, cannot relax
- only feels good when out doing heavy manual work in garden

generally unwell last six months

seen by Dr W.
gastroscopy - mild distal oesophagitis last Monday
colonoscopy 3 weeks ago
- haemorrhoids, few pelvic diverticulae

And could lend itself to any amount of second-run splitting the doctor desires. The doctor might even wait until the next visit to do some of the splitting, to reduce the added overhead of splitting information into multiple problems, where multiple of these could prove self-limited.

http://lists.gnu.org/archive/html/gnumed-devel/2002-05/msg00012.html