Re: [Gnumed-devel] CCHIT - SOAP notes

[Karsten Hilbert]

On Sat, Nov 07, 2009 at 10:16:29PM +0100, Hilbert, Sebastian wrote:

> requirement:
> 
> Complete and sign off note.  Print a copy for the patient.
> 
> Print preview is acceptable for verification.
> Note is retrieved from “draft” status, updates to note are captured, and note 
> accepts sign off.  System captures id
> entity of the user and date/time of finalization.
> 
> AM 08.04      The system shall provide the ability to finalize a note, i.e. 
> change 
> the status of the note from in progress to complete so that any subsequent 
> changes are recorded as such.

If *that* is the definition of "the note is signed" then we
already support that because for us *any* note is "signed"
in that sense: we record any and all modifications of a
note (including user ID and timestamp, of course).

"print a copy" - well, there's some support for exporting
the current note in Medistar import format - that can be
printed. Also, we support exporting the entire record as a
journal. That would include the note.

> AM 29.02      The system shall provide the ability to generate reports 
> consisting 
> of all or part of an individual patient’s medical record (e.g. patient 
> summary).

We support reports but at a very low level. For
certification it is probably better to use OpenOffice or
Crystal Reports or Jasper Reports connecting to the GNUmed
database.

> AM 30.02      The system shall provide the ability to generate hardcopy or 
> electronic output of part or all of the individual patient’s record.
> Date and time must be system generated and recorded automatically.

No problem :-)

> Looks like they require the SOAP note can eb printed and handed to the 
> patient. I wonder if it is acceptable to copy and paste :-).

Sure !!

> Furthermore they 
> talk about a draft status of a SOAP note. That makes no sense. Since you have 
> the audit trail anything you put in is for real and becomes a draft once the 
> note is updated.

It becomes "history", not "draft", but, yeah, once again we
are ahead of the requirement.

Karsten
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