gnumed-devel
[Top][All Lists]
Advanced

[Date Prev][Date Next][Thread Prev][Thread Next][Date Index][Thread Index]

auditing (was: Re: [Gnumed-devel] HL7 data sample for you.)


From: J Busser
Subject: auditing (was: Re: [Gnumed-devel] HL7 data sample for you.)
Date: Sat, 5 Mar 2005 16:04:51 -0800

At 5:44 PM +0100 3/5/05, Karsten Hilbert wrote:
 > > > We should have the ability to attach free text notes to results
 >We already do.
 where?
test_result.narrative or lab_request.narrative

For any one test_result, only a single .narrative would be stored, is this a preferred place in which a secretary's input "Phoned to Dr X, 2:45pm" could be stored?

Is it better for the secretary to enter a Soap item relating to the health_issue (visit) in which the labs were done, to input "Phoned to Dr X, 2:45pm"?

And if this action had been stored in test_result.narrative, and then it later happened that the pathologist phone the doctor to say there was an analytical problem and the result may be unreliable, would the clinic doctor audit the result to input this comment into test_result.narrative (resulting in an audited value)? Some might suggest lab results not be audited, and that instead an entry be made in clin_narr however I think auditing remains important. A test_result (like a blood pressure) could have been manually entered and it is only later realized that it was wrong.

The question of auditing makes me think a few things:

1. I don't believe the log_ (audit) tables have a log_comment into which to enter why the audit was done (Karsten?).

2. Even if such a field were added, might we wish only the briefest information input into this field (i.e. the clinical "trigger", source of info) whereas if there may be a *consequence* to the audit, we would prefer to have the *consequence* information put into clin_narr, for example maybe the patient needs to be contacted and their management changed. So maybe it should be automatic that when a record is audited, some entry in clin_narr is also required?

3. The possibility that a record has been audited makes it important for this information to be accessible from every clinical screen. It also suggests that the user needs to be helped to be able to visually pick out every item that has been audited (maybe color or a symbol etc).

4. and then if a user wishes to access the audit trail, how within a GUI would they indicate which item it is (among the many on-screen) whose audit trail they wish to examine?




reply via email to

[Prev in Thread] Current Thread [Next in Thread]