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

[Karsten Hilbert]

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

> 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 be documented in three places:

1) "S"oap of the encountlet it becomes known under

2) scan of the document giving a detailed account
   of what happened

3) a Caveat (pseudo-allergy) entry, say,

        "allergene": "iv fluids: O² drop"
        reaction: pronated -> airway obstruction -> O² sats @ 40% -> 
supination/suction/O² -> 98%

Nonetheless I have added support for soapU at least in
clin.clin_narrative pending actual exploitation as per
opportunity.

Karsten
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