I take in all you say. You must be fairly unique amongst doctors Karsten, or or perhaps it is the german system, or the sort of clinic you work in.
Reason: I've perused many many thousands of clinical records from patients from many hundreds of doctors in my time, and it exceptionally rare to find structured notes. In my 'on-the-ground' tutoring of GP's in the use of clinical record programs, and in projects where we wrote the software specifically to enforce entering a reason for encounter (for research projects), we had a huge problem trying to educate doctors how to use that, and also if they knew how, getting them to fill it in. In my own consultations I reckon there may be about 50% of consulations I could tag with something sensible. Must be different in Germany? Regards Richard On Sun, 18 Sep 2005 11:00 pm, Karsten Hilbert wrote: > On Wed, Sep 14, 2005 at 08:19:45AM +1000, Richard wrote: > > Regarding your comments on complexity I agree we have to > > look beyond the single encounter visit. > > Beyond the single *problem* visit, right ? > > > As you mentioned, having to input SOAP notes as we do > > currently, we end up with > > > > S ... > > O ... > > A ... > > P ... > > > > S ... > > O ... > > A ... > > P ... > > That is what I would expect. It also fits my workflow quite > well. I capture what I am told, what I find, what I think > about it, what I do about it. I am going back and forth, of > course, but in general that's how I work. > > Notice how this does not predefine how the data is > *displayed* later on ! The EMR is a tool to make things > *easier* for us. We can use one format to make input follow > our workflow but use *another* format to guide our reception > of information later on. The requirement for this ability is > that the input is in some sort of structure. That's > precisely the point. On paper I am forced to write down the > notes in a way that will facilitate easy reception. No > reformatting is possible unless I have the notes > transcribed! Such *is* the power of using a machine and > using structured data. That's exactly why we want to give > the machine some idea of what's what ! > > So, in the end, the statement "we end up with ..." is wrong > (thanks $DEITY). What we end up with is a bunch of unordered > lines of text thrown into an opaque bag called "table". It > is *our* responsibility to grab the proper lines from this > bag and display them any way we see fit. For that to be > possible we need to add metadata to the text when throwing > it into the bag: who, when, what type of text, which > encounter, which problem, etc. > > > The essence of the encounter which we as a doctor > > immediately grasp is that of poor diabetic control > > Hence we use "poor control" for the AOE of the encounter and > "foot problems" and "high sugars" for the progress note > assessment lines. > > > Diabetes > > ===== > > - poor control: > > Having trouble adhering to diet. Checking ~ 2x daily, staggered > > times, 9-13 mmol/L > > last A1C 0.09% ( is it under O we would comment on test results, > > under A?) > > Agrees to incr meds while continuing effort at wt loss > > Incr metformin 500->850mg bid > > > > - diabetes mellitus (foot care) > > Noted slight drainage on socks past 3 days. No > > pain/red/fever/trauma but new shoes 7d ago. > > (Details of exam) > > Assement Whatever > > Plan Whatever' > > And yes, one could reformat the above notes into that sort > of display - that's precisely what I asked for when I wanted > HTML snippets for how you guys want the notes to be > formatted. The above is simply: > > $health_issue > ============= > - soAp > Soap > sOap > soaP > > - soAp > Soap > sOap > soaP > > (Apart from the fact that we cannot currently have two open > episodes at once.) > > > The more and more I play with this type of data entry in my > > consultations, , the more I'm coming around to Malcom Irelands view (and > > I suspect Horsts and David Guest's as well) that we need a large single > > textbox to collect all the information we type in, > > Sure, no problem. If you guys want a single text box you can > have it. Simply save all the text under, say, Soap (or > whatever category) and be done with it. Within that > narrative line the information can be structured any way. A > viewer can be made intelligent enough to not destroy the > pre-existing formatting and to ignore empty categories. That > way within the structure unstructured data is saved. The > additional structured data (scripts, vaccs, etc) can happily > coexist. > > Karsten _______________________________________________ Gnumed-devel mailing list [email protected] http://lists.gnu.org/mailman/listinfo/gnumed-devel
