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

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] encounter edit before final save
Date: Mon, 11 Aug 2008 23:51:39 +0200

> Karsten - you just described similar scenario as Rogerio. I could provide
> my own examples. So it is common to many (if not all) of us.
> But there must be some person (= provider) who decides to end the
> encounter and sends patient home (or to the hospital, etc.). I would like to 
> review
> all procedures, test, recommendations before letting patient go. This is
> the moment to close an encounter. 
Nah, you are confusing "end of encounter" with "termination or transfer of 
care". Of
course, "termination/transfer of care" eventually *becomes* the "end of 
encounter". But only
eventually so, in retrospect. There's no use in declaring something which I 
don't know such as
"the encounter ends now" rather than something I DO know, namely "the current 
encounter lasted
at least until xxxx". And, yes, I can explicitely set this in the encounter 

> Don't you save/print/give to the patient any report at the end of
> consultation?
Why, of course and this happens IN the encounter, not after it, so the notion 
of "must finish
encounter before writing report" is conceptually flawed :-)

The encounter will eventually turn out to have been finished after writing the 
discharge note, no,
wait, after printing the discharge note, wait, no after printing the forgotten 
repeat script, wait, no,
after the front desk staff handed out the next appointment, oh, wait, after I 
called the patient
back into the exam room because I forgot to administer the tetanus shot that 
was due...

We all know the routine !

> I do, so sometimes I would like to add or change something in the
> progress note entered at the beginning. This way I can print it and it makes
> sense. If I print a list of progress notes for one encounter, where latter
> corrects the former, it becomes cluttered and hard to read. Here we come to
> the need of editing them, which was the primary topic of this thread. 
And I fully agree with that. It simply isn't implemented yet. Historical 
versions won't be displayed
by default, only the most recent one of a certain lineage.

> From the legal point of view AFAIK you must not modify patient data after
> discharge.
What about typos ?  That's a blurred line. Is a "-" a typo if it should have 
been a "+" ?

> Also, while billing is not the issue for me at the moment, I
> could not request billing until I finish the consultation, so there are reason
> to mark encountered "closed" explicitly.

Again, this is mixing if not confusing billing with medicine. While I agree 
billing is essential (after all,
I eat bread, too) I do NOT want billing in any way to influence my medical 
decisions or documentation.
There are studies that billing requirements do in fact change what is 
documented and thereby falsify

> From this point of view,
> "closing" means marking it "read-only". Until it is "closed" you are free to 
> add
> data like now, and it would be nice to be able to change data as it is
> planned.
OK, now *that* is an interesting point you make. It might well be worth to 
eventually introduce
the notion of "freezing" an encounter.

This could happen at an appropriate point in time after a new encounter has 
been started. However,
I am not sure how much that really buys us because we are essentially freezing 
the state of the EMR
anyways when we dump the database, hash the dump and have the hash signed by a 
digital notary.
Which one of our users does on a regular basis. Such a signed dump hash 
includes all audit trail
information as available at the point in time of dumping.

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