Re: access to review audits (was Re: [Gnumed-devel] encounter edit before final save)

[James Busser]

> On Tue, Aug 12, 2008 at 12:59:33PM -0700, James Busser wrote:
>
> > trainee doctors... managing a patient under my care...
> > ... *insisted*... Staph aureus growing in the patient's blood.

On 13-Aug-08, at 1:53 AM, Karsten Hilbert wrote:

> A simple confirmative phone call to the lab
> would resolve the situation.

Well, now I have had my laugh for the day ;-)

> I am not sure I quite appreciate how this relates to editing  
> narrative.

It was an indirect analogy being that a lab result was written into  
the record, was seen and acted on by a provider. The result was then  
changed in a way that gave no indication that a change had occurred  
and to make matters worse there was no way *within the record in  
question* to identify (audit) that the change had been made. It is  
not a question of a widget not having been written... the "original"  
was now "gone". As Rogerio indicated, this should NOT BE (allowed to  
be) POSSIBLE. The same is true with narrative. I am having trouble  
understanding that there would be a difference.

> After all
> one doesn't assume the trainee is involved in a deliberate
> coverup of something.

No, the trainee could have been looking at someone else's record, and  
it may have been a simple mistake, or else an early indication of  
incompetence.

I declined, for the purpose of this thread, to get into whether it  
even made sense for the patient to be given antibiotics as it was not  
clear that there was a reason to suspect septicemia and the patient  
was not that sick and an argument could have been made to take  
another set of cultures even if antibiotics were to be started.