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From: | Richard Terry |
Subject: | Re: [Gnumed-devel] need assessment from fellow clinicians |
Date: | Thu, 01 Jul 2004 09:23:57 +1000 |
User-agent: | Mozilla Thunderbird 0.6 (X11/20040503) |
James Busser wrote:
Quoting Richard Terry <address@hidden>:How do you handle multiple RFEs within a single visit /encounter? Do you SOAP each of them or, in the same way as I deal with hospital inpatients, do you ever combine all symptoms onto "S", all physical exam into "O" but then, depending on the problem(s), combine some and/or split others into separate "AP"s.
I think they need to be individually soaped (I do this in my notes at work)
I also like the concept of Beratungsergebnis or Assessment of Encounter. I call this a 'summary of the consultation", and it may go something likeAbdominal pains ?diagnosis, if doesn't settle > review or Abdominal pains ?gall stones > abdominal u/s review afterOr Leg swelling > probably DVT > doppler > review today etcI also like this concept, though it draws from the A&P of SOAP and I am fuzzy on the distinction. Is it meant to provide an abstraction, when an encounter contains multiple RFEs, each of which *might* have a separate SOAP (or, at least, separate AP components?)
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