Re: [Gnumed-devel] GNUMed SOAP vs SOAPless progress notes

[Karsten Hilbert]

On Thu, Dec 01, 2011 at 12:59:04AM +0000, Jim Busser wrote:

> Here is an example of the problem that I am having to decide inside which 
> SOAP category to place information.
> 
> Suppose I manage to access external records of a patient from which to 
> prepare a summary. I determine that
> 
> During their operation, where they received about 2L of IV fluid, they were 
> observed to obstruct their airway and quickly drop their O2 saturation to 40% 
> but that on being turned from prone to supine and suctioned, they improved to 
> 90% and, within another few minutes, 98% (on supplemental oxygen) and that 
> their blood pressure and pulse were normal throughout. They were briefly 
> converted from conscious sedation to general anaesthesia (intubated) but 
> improved quickly and were later able to be extubated in the ICU.
> 
> Part of what makes it hard is that it is not a patient complaint but rather 
> an abstracting of a record of an event. The other part that is hard is that 
> it is subjective (in that *I* made no measurements) but it is objective (in 
> terms of a description of what is documented and which included second-hand 
> measurements).

To *me*, this would definitely go into Soap.

I'd fully expect a document describing the above - likely
within a discharge letter - attached to the episode.

Karsten
-- 
GPG key ID E4071346 @ gpg-keyserver.de
E167 67FD A291 2BEA 73BD  4537 78B9 A9F9 E407 1346