Re: [Gnumed-devel] editing of progress notes

[James Busser]

Quoting Richard Terry <address@hidden>:

> ...editing a progress note from another user SHOULD
> NEVER BE ALLOWED...
> Why would you allow that.

>  I write my clinical notes. If I make changes within my current session,
> those changes should make up the medical record (not the bits I changed which 
> should not be recorded). The record should not be committed to the database 
> until I (the doctor) have decided that they should by hitting the save key, 
> or the consultation is over.

There can be a useful distinction, if you have to interrupt what you are doing 
(e.g. leave the office in an emergency) between "Save" meaning "I do not want 
to lose what I have put in so far", and "Sign" meaning "I am satisfied that 
what I have written is accurate and sufficient". Related to this, Horst had way 
back made a proposal (post 0.1) concerning "limboed" items which I captured on 
the wiki with a link from the DevelopmentReference page

> If I the doctor,  want to then amend/change, then this change is added 
> sequentially to the record. If someone else wants to add/change, it is added
> sequentially to the record.

I do have a question here... what if it is determined that information 
contained within a note is *wrong*? If that error remains available, and if 
there is no indication to the person viewing that it is *wrong*, that viewing 
person could be interrupted before getting to the amendment. Maybe the "nicest" 
(but difficult) solution would be to be able to mark up text inside a note, or 
else to insert a link or reference alerting / anchoring to a comment located 
inside a later note. Alternatively a uniform way that the GUI (through all 
clinical middleware?) be able to inform the user (visually and/or interactively 
when choosing to view the content of a note, value etc.) that an audit trail 
exists for the item.