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Re: [Gnumed-devel] another vista at abnormality/relevance flags


From: James Busser
Subject: Re: [Gnumed-devel] another vista at abnormality/relevance flags
Date: Wed, 09 Apr 2008 16:37:40 -0700


On 9-Apr-08, at 1:35 PM, Karsten Hilbert wrote:
3) No, because neither am I responsible nor am I the first
   to see this result (and they did sign it). In which case
   I still *can* sign if I choose to.

But there wouldn't be a point... wait... I think above you are using responsible to denote the doctor who ordered the test. I f I am neither of the above but the patient sees me for a related or unrelated problem (say in the absence of the usual GP) after the results had already been signed, the question is whether I somehow want to make a record of having seen the results.

However if there is no disagreement with what had been already entered for whether they were abnormal or clinically significant, I don't see the point of recording "I have seen those specific results and was aware of and agreed with the recorded interpretation" however are we then going to document every read-activity like the review of documents by re-signing already-signed documents?

To me, the answer would be no. At most you would enter into a *** progress note *** something like

"documents <optionally identified> and results <optionally specific ones> noted"

if those would have been important to updating a clinical assessment.




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