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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 11:56:34 -0700

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.

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