Re: [Gnumed-devel] encounter edit before final save

[James Busser]

> On 13-Aug-08, at 3:54 PM, Karsten Hilbert wrote:
> There isn't really an explicit notion of "set". If I enter
> SOAP notes under one and the same encounter for one and the
> same episode they end up as one combined list of soap rows
> on equal footing with each other.

Supposing a doctor sees a patient who may have a viral URTI or  
bronchitis or pneumonia.

Suppose the doctor had the benefit of an X-ray service within the  
building and therefore chose not to document a formal plan until  
after getting a quickly-available x-ray. The doctor might in this  
situation create a partial progress note

        S (symptoms)
        O (findings)
        A  viral URTI / bronchitis vs pneumonia - need CXR

If the doctor exercised the option to minimize the current instance  
of the GNUmed client, essentially "pausing" this note until the  
return of the patient, they could revise the "O" to be:

        S (symptoms)
        O (findings +) CXR normal or infiltrate or ...
        A (assessment that is now assisted by the X-ray result)
        P (plan based on the above)

	admittedly the medical action of sending the patient for the x-ray  
has been buried in the "O" however especially if a doctor was not yet  
ordering in GNUmed they may wish the flexibility to make their entry  
in this fashion and it is nice to not overly constrain what can be a  
judgment decision by the clinician on how to document. Is there  
however a caveat with respect to a "timeout" after which the database  
will not allow the paused instance to write into the backend? Where  
and how would this configuration be set?

If instead the doctor exercised the option to make 2 notes within the  
encounter, it might go like:

        S (symptoms)
        O (findings)
        A  viral URTI v bronchitis v pneumonia
        P CXR

        O CXR shows infiltrate (verbal from radiologist)
        A Pneumonia, community-acquired, not severe
        P Patient counseled. Rx... Return in ... If deteriorates...

a few questions now:

1) after committing the second SOAPlet (the OAP) would GNUmed  
presently display within the encounter:

        S (symptoms)
        O (findings)
        O CXR shows infiltrate (verbal from radiologist)
        A  viral URTI v bronchitis v pneumonia
        A Pneumonia, community-acquired, not severe
        P CXR
        P Patient counseled. Rx... Return in ... If deteriorates...

or (maybe better)

        S (symptoms)
        O (findings)
        A  viral URTI v bronchitis v pneumonia
        P CXR
        O CXR shows infiltrate (verbal from radiologist)
        A Pneumonia, community-acquired, not severe
        P Patient counseled. Rx... Return in ... If deteriorates...

2) later there may come a document -- the official report from the  
radiologist -- which would be added via the document viewer. Addition  
of the document would create a new encounter, correct, of type ??

The doctor (or assistant) should wish to associate it to the episode  
in which can be found the encounter (or encountlet) above.

How would the new encounter (which represents the addition of the  
radiology report) appear in-line below the above-described and listed  
SOAP rows, for example in the journal?