On Wed, Jul 03, 2019 at 05:35:07PM +0100, Thomas Beale wrote: > well my epistemological (and non-MD) view is that thinking of a SOAP > structure not just as the headings for a 'SOAP note', but as the headings > for a 'problem summary' or similar, could create better quality > problem-oriented data in the record. If there was a small catalogue of > 'problems' (anything for which a SOAP structure summary already created in > the past), each with a title that could be anything from a patient issue > (chronic back pain) to a solid Dx (diabetes), then the UI could show that > list, and when a new encounter occurred, the doc could create (structured) > event notes as usual, and also (by some efficient drag-n-drop) choose an > existing problem and attach some of those notes (e.g. patient stmt, phys > exam, etc) to it, rather than just creating a new SOAP note. Or it might be > the other way around, where one or more problems is chosen from the list, > and the notes created inside them visually, which would still create > independent event notes, and links from the relevant problems (i.e. the link > could be removed or ignored in the future).
In GNUmed, when you first go to the Progress Notes editor tab it will auto-open a new as-yet unattached SOAP editor PLUS one SOAP editor pre-attached to each of the problems touched upon during the previous encounter. Also, within that tab, more editors can be opened for other problems by selecting from the problem list which, by default, filters to active problems, but can be extended to all problems. Each encounter will have one SOAP structure for each problem touched upon (if anything was documented under a given problem). Karsten -- GPG 40BE 5B0E C98E 1713 AFA6 5BC0 3BEA AC80 7D4F C89B _______________________________________________ openEHR-clinical mailing list [email protected] http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org
