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

From: Rogerio Luz
Subject: Re: [Gnumed-devel] encounter edit before final save
Date: Mon, 11 Aug 2008 15:28:10 -0300

ok Karsten I see your point, but a CLOSE CONSULT button would really improve the way a clinician would look at the hole story ...
here goes my view:
Patient A comes in ... consultation, physical, past history, etc ... send him to X-ray
Patient B , C, D
Patient A returns in the same day ... as we OPEN him "message: this patient has been seen by a physician in this same date, do you want to open a Complementary consult?" YES NO ... if NO the event will not be merged and a new episode will be made. If YES the event will be merged and a new episode will NOT be made, but the COMPLEMENTARY CONSULT will be notated in the record.
It gives a little more autonomy (for billing also, I guess) to the provider of care.
It also makes a step to what I feel is greately needed in GNUmed: a signal TO THE PROVIDER that he is about to close the consult to that patient.
There should be no question on the provider´s mind on WITCH patient he is working on. So if your patient has to go home for those test he forgot, the provider has two choices: close and continue with other patients OR let him open and try at the admission desk to get that fax from the lab, but in that case NO OTHER patient can be worked on until he CLOSES the consult. 
It is basic chronology :when a timestamp of "end consult" was made on the bottom of the patient´s file he no longer is in the care of a given provider, so if he bashes his head on the way home the timestamp will show it was AFTER the consult ended and not the POVIDER that bashed his head :))))))) 
Sorry for the joke. But these are consirations I feel need to be made before we can make GNUmed the general EMR it is supposed to (and will)  be. 

2008/8/11, Karsten Hilbert <address@hidden>:
> > - the impossibility to edit anything after it is done but BEFORE I close
> > the consult

That can't be true simply because there is no explicit way of "closing a consult". A consult is only
ever closed implicitely - by starting another one and considerung the new one the current one.

Chronicity defines consultations.

> That's also a big trouble for me. As far as I understand, the purpose of
> auditing is to make changes possible, but preserve the history - right?

> So why disable editing?
It is not disabled. As far as editing previously saved progress notes go, however, it is
simply not yet implemented :-)

> At least it should be possible to switch notebook
> tabs
> and get back to progress tab to make additions/corrections until
> clicked "save" button,
This is possible today (and anything else would be stupid) -- but I believe you found out
how already.

> which will close the encounter
It will not close the encounter. It cannot, because the encounter can well be carried on
by another provider. We have this every day. Patient comes in, sees doctor in exam room, is
transferred to monitoring unit for a while, sees radiology nurse for xray, back to monitoring,
sees doctor again, transferred to septic operating theater - all in the same encounter in the
course of, say, 3 hours. During normal office hours. Happened to me just a few hours ago.

> I would rather
> stick
> to radiology and surgery report handling I try to prepare.

It is a good idea to get a first, easy use case going for oneself. More complex ones will come
about anyways.


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