Re: [Gnumed-devel] encounter edit before final save

[James Busser]

On 11-Aug-08, at 1:35 PM, Jerzy Luszawski wrote:

> If I print a list of progress notes for one encounter, where latter  
> corrects the former

Part of what was under discussion I may like to call a "fragmented"  
encounter, in which a patient thread becomes equivalent-to-docked,  
while the patient briefly leaves in order for something else to be  
done, whether that involves something on the part of the patient, and/ 
or if it is just that the doctor in the meantime works on other  
patients.

Is it useful to think and talk in terms of a "fragmented" encounter?

To interrupt a visit for missing documentation to be obtained, or for  
an assistant to perform measurements, is one thing, but to send a  
patient to get something done (like a test), and then come back to  
"continue" a visit, would have been a clinical, medical management  
decision. Think of the patient with chest pain being sent for the EKG  
upstairs. One can imagine quite different outcomes depending on what  
happened to the patient after you sent them out of the exam room, and  
what the EKG showed. I would want to be able to make an entry  
recording what I found, and what I had explained to the patient, for  
the pre-ECG and post-ECG fragments. As pointed out, it is possible  
that some second doctor sees the patient after their return. Thus, in  
situations where it would be desirable to document each fragment, it  
sounds like the doctor(s) may need to decide to make 2 encounters.

Other doctors may rather wait until the patient is back and add to  
their initial SOAP note to make a single "official" note for the  
encounter. This will only be possible after an "edit existing SOAP  
note widget" is implemented.

One user pointed to the need to be able to bill unambiguously if  
different doctors serviced different fragments of a visit. I cannot  
see that you could have a second doctor revising the preliminary  
entries of the first doctor... the outcome to my mind would be as if  
the first doctor did not make any proper (medicolegally defensible)  
note. The "official" note would then belong to, and responsibility  
fall purely on, the second doctor.

As to billing, I would point out that the audit ability should make  
it possible for a doctor who was not the original signer to make a  
correction in an entry, for example where the original doctor mis- 
entered right vs left and there is value making sure that no error  
gets perpetuated. Depending on convention the person correcting might  
enter e.g. [correction: right]. But while this would become the new  
note, signed by a new doctor, it would not change which doctor  
actually provided the consultation. Billing software may therefore  
not rely on the signer to determine under what doctor the billing is  
charged, especially if two doctors see the patient in a practice  
where it is desired to capture the encounter as a single SOAP note.

Maybe this makes it importance for billing to intelligently piggy- 
back without being wholly reliant on the part of the GNUmed design  
that is needed to make the record of care to make sense.