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

[James Busser]

On 13-Aug-08, at 10:48 AM, Rogerio Luz wrote:

Couldn´t the RR(RR) field in the left ... in the list of exames be made some other colour ... for example RED ??

 

Do you understad? when something is edited after a save it would turn RED, so when you open the exam list ... RED means I need to look this again?

And again, and again? Just you, or everyone in the practice? At every subsequent viewing, or just once?

For lab and other externally-originating information, responsibility does need to be taken, and it is useful -- and already supported -- to set apart operationally and visually what has not yet been signed. This is achieved through inbox notifications ("you have unsigned results") and visually (in the viewer).

For lab and other tests, there can be a requirement for the doctor who ordered a test to sign it. Thus if a test or a test revision was (in that doctor's absence) signed-off by a colleague, some jurisdications may require, and some groups may desire, that he first doctor who had ordered the test (also / additionally) sign it off.

We are not sure yet about the need to signal (and for anyone to additionally sign) a revision to a progress note. GNUmed presently treats progress note as implicitly signed by their creator and implicitly signed by whoever would have revised it.

Based on the way GNUmed works, any update to a clinical record is really a revision, and is captured in the audit table. Therefore, if you "save" an entry when the patient steps out to get an X-ray, and then "update" the progress note to "finish" it, this is a revision. If every "technical" revision were to be signalled visually at the top-level of the GUI, it would be a challenge to keep / make this information useful. It is almost as if a second-level need has arisen to make sure that people know that some things have been changed but to ignore the fact that other things have been trivially changed.

If the reviser of a note was the same person who had created it, what would be the value to draw attention to it, unless there were some material clinical consequence of the revision? If we would need to visually signal every item that had ever undergone a revision, no matter how trivial, this would seem to me a problem. For the moment, Karsten has nested the information down inside the item detail.

There does sit, on the modifier of clinical information, a responsibility to make sure that any who would be affected are notified. 

Within GNUmed it should be very possible to determine, from the patient journal, any management decisions that were made using, and would have been affected by, the information that is now being changed. Taking appropriate action should be the most direct consequence of any important revision to an entry. It is always possible, and may be important, to cover off such things in an additional note which may be the best way to handle events of importance.

Prog note of August 6 recorded patient referral to cardiologist when actual discussion & pat expectation was referral to respirologist. Cardiology referral cancelled. Respirologist referral booked. Pt notified.

Some might ask "why then also (bother to) alter the original note"? Well, if you embed -- in the referral to the respirologist -- a progress note which incorrectly recorded a plan to refer to a cardiologist, the note would not make any sense.