On 15-Sep-08, at 5:04 PM, Rogerio Luz wrote: I think that more important than the formatting of the SOAP is the organization... can we take a vote to see whether or not to place the "Patient Request" above the "Subjective" ?
I vote yes.
I agree, it should be
1) "Patient request" first, which I would even relabel to "Purpose of visit" (or "Visit purpose") which -- while it *may* have been at the request of the patient -- may alternatively have been at the request or at the direction of the clinician. "Purpose of visit" (or even just "Purpose" if it may not be a visit) would more correctly cover the general case while still adequately prompting for the patient complaint or request, when relevant.
2) the remainder of the Subjective, Objective, Assessment and Plan.
And later I think we should vote to take out the term "Foundational" and go for "Health Issue"
yes and later still vote to make the SOAP editor speak *exactly* the same as the viewer (now it says things like Objective in the viewer and "Findings" on the editor)
let me look at this more. Now that I am daily running Debian in a VM on my Mac I am better able to do some proper testing of what it will be like to use GNUmed. I think we have not yet adequately captured -- at least not well enough to make clear -- how encounters work and how they are displayed. I am realizing that an encounter is not necessarily an interaction with the patient nor one session with the chart nor a single visit, necessarily so this needs to be better re-expressed, which I am feeling my way through :-) |