2009/6/29 Karsten Hilbert
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On Mon, Jun 29, 2009 at 05:31:42PM -0300, Rogerio Luz Coelho wrote:
> Well, I was tought the Present Complaint system
Believe it or not, I haven't been taught ANY system at med
school ! I pretty much partially found (SOAP) and partially
re-invented (issue, episode, encounter) it myself ...
I was lucky just about early enough to find literature that
channelled my re-"inventions" onto the right track to not
get too far with making my own mistakes and stick with them :-)
The first time I came into contact with SOAP was during in
internship in Chiang Mai, Thailand (!) -- I was hooked
immediately. At the time I was already involved with GNUmed...
> The greatest problem I see for your problem (or recomendation) is how
> to have a multitude of ways to do the recording, although in GNUmed we
> are (as far as I understood) limited by HOW the Database stores
> information, so we do not have a Systems Review field inside the
> Database, we have a sOap field that CAN be used as this,
Not only can it be used but a more specialised UI (or
plugin) can take advantage of the following facts:
- there can be more than one sOap row per encounter per episode
- such sOap rows can be tagged to make them distinguishable
(one could tag one sOap row musculoscelatal and another one
neurological)
> and I myself
> use then a "Text Expansion" to get all the systems in that field so I
> can manage them in a quick way with the patient.
Nice ! Care to share that with the community ?
Ok here it goes
when I type " [S " (for Sistemas , wich is Systems in Portuguese ;) the text is translated to:
- Pains =
- Head Eyes and Ears =
- Neck =
- Troat =
- Lungs =
- Heart =
- Abdomen =
- Skin =
- Intestines =
- Urine =
- Sleep =
- Eating Habits =
- Excercise =
- Flavors of choice =
- Hours of day =
- Hot or Cold =
- Milk consuption =
- Hair and nails =
- Body type =
- Pulse =
- Tongue =
:)
That can remind me of anything I haven't asked in a first consult. I have the last set of values for Acupuncture, so it's suppose to be strange like that :-)
Rogerio
> This is just a way to make GNUmed relate more closely to my practice,
It's also how I envisioned this to be used.
> but I think IMHO that the SOAP is the method that gives us the most
> flexibility in storing information, short of not making any divisions
> on the patient's chart and storing everything as a single batch of
> text (wich does not seem so grand in the long run ;)
I fully agree !
Karsten
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