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

[Karsten Hilbert]

On Thu, Dec 01, 2011 at 08:57:35PM +0000, Jim Busser wrote:

> > Soap does not mean "Patient Complaint". It means "History
> > Taken".
> 
> Well, 'S' only means subjective.
> 
> In spite of living and working in North America, and
> training at a medical school which taught both Weed's POMR
> as well as SOAP notes (which I cannot recall if they were
> part of Weed's construction) I cannot for the life of me
> recall ever seeing a SOAP note documented in reference to
> anything other than a direct patient interview / assessment.

OK, I have to say this is how *I* am used to use Soap (and
how I see it being used here).

> >> Maybe labelled
> >> 
> >>    Non-SOAP narrative
> > 
> > That doesn't make sense.
> > "Uncolored color"
> 
> No, I did not write or propose
> 
>               Non-SOAP SOAP
> 
> it is only your insistence that clinical narrative cannot
> be anything other than SOAP, and so cannot be permitted to
> exist outside a SOAP formalization, except to be rendered
> and treated as invalid or not-yet-valid.

Your qualification "*clinical* narrative" is important.
That's what I meant. I am not all that averse to adding U to
signify clinical-but-as-yet-Undecided SOAP.

> It is precisely why
> I wrote Non-SOAP (somewhat facetiously, admittedly, because
> an actual label might better be something else).

I misunderstood it to mean Non-(clinical-)SOAP.

> Seemingly, however, it is being implied that the doctor should be happy to 
> see the label
> 
>       Non-clinical notes
> 
> and so we have an important problem here! ?
> 
> > Clinical narrative is *always* SOAP, except which may not
> > have been decided yet.
> 
> Above -- where you may mean it is *conceptually* "always SOAP" -- we are 
> getting closer to possible agreement …
> 
> > If narrative is not SOAP then it is not *clinical* narrative
> > and needs NULL as category.
> 
> … but now we are disagreeing again.

Not really :-)    If it, indeed, IS SOAP it can be decided
which or not. But it surely either IS clinical (and thereby
SOAP) or NOT (and thereby NULL=admin).

What you seem to be arguing for is explicit modelling of
clinical=SOAP-but-undecided in the form of SOAP (SOUP ? :-)

I guess that's conceptually sensible.

> - we are maybe proposing that 1, 2 and 3 are all 'S' despite that these 
> actually contain 'O' and 'A' and 'P'

I agree with your assessment.

Which to document how is up to the discretion of the
documenting clinician.

I should think some of this assessment might usefully find
its way into the Wiki ?

> despite that in most EMRs the clinicians likely clutter
> this up with the clinicians' to-dos which would better live
> elsewhere (which GNUmed supports in Waitlist).

That's BTW quite a misunderstanding (or else "creative use").

The waiting list is intended to hold and communicate
*patients* waiting in the praxis to be seen. That's the
design goal.

>       Plan
> 
> should need to take into account the goals, the attainable
> targets that have been realistically set but we have no
> place for these to live, and so they either get re-written
> from time to time in *some* of the notes and risk getting
> lost,

Put them into the episode synopsis.

Karsten
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