Le 02/04/2018 à 19:45, GF a écrit : > 1- What stands AP)SA(A'P’) for?
I guess that you know the SOAP as the 4 main "chapters" of a clinical encounter (https://en.wikipedia.org/wiki/SOAP_note). From Lawrence Weed's concepts, a patient encounter should be recorded as a "grid" with problems as columns and SOAP elements as line. This concept is theoretically sound for acute care since it starts with patient's verbatim of the reasons for encounter (S standing for Subjective - which is truly dated!). In the current "state of the medical art", always more chronic care oriented, a patient often comes with an ongoing list of problems and treatments, hence (AP)SO... and leaves with the same or a different list of A and P, hence (AP)SO(A'P'). 14 years ago, I worked with a knowledge management research team on establishing both the theoretical aspect and the user interface of such concept, by the name "virtual staff". To make it short, imagine the Ligne de vie, with the vertical "now" separator... then spread this separator as a curtain in order to open the patient encounter as a cognitive map located between the past (AP) and the future (A'P'). > > Here below some missing topics we need to have agreement about > > 2- Thinking about the health and care provission documentation process > there are: > - Observation process > - Evaluation process (including, and restricted to, diagnosis, diff > diagnosis, problem kist, episode list, etc > - Planning process > - Ordering process > - Execution process of acts I am currently writing a paper (in French) telling a story of "boxes" and "bubbles". Boxes are care places (say organizations at large) with roles within a domain. Bubbles are the patients (say persons at large) with a "polar reference frame vision" about "who is around and among them, who is close or not so close". In the usual system, only boxes operate an information system... and they are pretty bad when it comes to "continuity of X" (replace X with care, education, employment, etc). Now, let's suppose that the reference information system is in the bubble. And that service providers are just considered as contributors that can join the current team that surround the person. In the ongoing paper, I am trying to describe what happens when "a bubble steps through a box"... and it is an amazing model to make many things clear! > > 3- We need to recognise that some data is de novo, other data is > repeated after a querry > > 4- Systems need to be aware that some data is directly health care > care related, other is administrativem process oriented > > 5- When that what is documented is used in shared working processes we > need a common vocabulary: i.e. System of Concepts for Continuity of Care Thanks to François Mennerat, a glorious CISP Club founder, we have been aware of Consys for many years... but "so many years" is also the problem! Philippe
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