Re: [Gnumed-devel] Translation help

[Karsten Hilbert]

On Thu, Jan 28, 2010 at 05:28:52PM -0200, Rogerio Luz Coelho wrote:

> I wonder if anyone would mind to give me a real life example of RFE and AOE
> 
> as I see it:
> 
> - patient comes in, tells the secretary he has an appointment with Dr. Spok
> for his back pain (RFE = back pain appointment)

Yes. To the secretary's best knowledge the Reason For
Encounter is "back pain". It is debatable whether it should
be "back pain" or "back pain appointment". The reason the
patient came (back) is the back pain. The appointment only
serves the purpose. But that's a minor difference.

Once the patient is in the exam room the RFE may actually
change: the patient may not have wanted the secretary to
know that they came for fear of having contracted some VD.

> - Dr Spok starts a new episode: Back Pain

Unless the back pain has already been treated before within
that episode.

> / wich starts a new encounter

In fact, the encounter has already been started,
technically, when the patient was activated by the
secretary.

> - Dr. Spok goes and does a Vulcanian-Karate-Chop (TM) on his spine and sends
> him home pain free and with orientation to come back next week (AOE = return
> in 7d for reavaluation of back pain)
> 
> Is this it?

Yes, this *could* be it if that's what you want. However, I
would put the "come back in 7 days" into the soaP line. The
AOE is rather like a "summary" of the encounter. Personally
I'd write something like

        AOE: "?non-complicated back pain, ?resolved"

It's not the instructions or plan, it's the post-encounter
assessment of the situation.

Karsten
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