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

From: James Busser
Subject: Re: [Gnumed-devel] encounter edit before final save
Date: Tue, 12 Aug 2008 13:23:39 -0700

On 11-Aug-08, at 1:24 AM, Jerzy Luszawski wrote:

The more likely scenario is that a patient comes in, the consultation starts, then the patient is sent to, say, ECG or x-ray, in this time next patients
come in, then the first one returns, and the natural way would be to
continue "paused" consultation. Of course you can have each procedure as separate encounter: first part of the consultation, lab, radiology, final part of thnue consultation,but this will make it difficult to analyse all data as a whole, to generate a report from the consultation, and to prepare billing data. This is my point of view. Other may have different needs and
different formal requirements to meet.

On the question of "caching" information prior to "finalizing" a note, we do not have any method presently available, other than to actually *write* the data into the back end.

As mentioned, only after an editing widget is written will it be possible to edit the note in order to "finalize" it, if it was not *already* final.

Even once an editing widget would be available, the first "writing" would serve a dual function of "caching" as well as serving as the "possible / assumed final". Only after a note would be edited would the note become "relatively more final". Since any note will have the capability to be corrected at a later date, we can never know that a note will never change, however that is no matter. All that is important to the person making the clinical decision is the state of the information at the time that the decision is being made.

What *appears* needed seems to be a workflow tool in which to distinguish, and be able to make selectively available, those notes that we knew were incomplete, from those notes that we believed complete.

This is sounding a lot like "you have unsigned lab results"

It sounds like people are arguing two levels of "save", one being "cache / keep this information" and the other being called by some "explicit save" by which they seem to mean "I am satisfied that this is now in a form that can stand as a record of this encounter". To me, this means the same as "sign" so we are potentially, in a multi- threaded (multi-issue) encounter, talking about

- Clear     vs     Save     vs      Save and Sign
        <the in-focus> issue SOAP note elements in this encounter, versus

- Clear     vs     Save     vs      Save and Sign
        <all> issue SOAP note elements in this encounter

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