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Re: [Gnumed-devel] editing of progress notes
From: |
James Busser |
Subject: |
Re: [Gnumed-devel] editing of progress notes |
Date: |
Fri, 4 Mar 2005 11:32:46 -0800 |
User-agent: |
Internet Messaging Program (IMP) 3.1-cvs |
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.