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access to review audits (was Re: [Gnumed-devel] encounter edit before fi

From: James Busser
Subject: access to review audits (was Re: [Gnumed-devel] encounter edit before final save)
Date: Tue, 12 Aug 2008 12:59:33 -0700

Not long ago, I was temporarily very unhappy with the trainee doctors managing a patient under my care, on account for having begun a patient on antibiotics for what they *insisted* was Staph aureus growing in the patient's blood. Together we re-examined the patient's hospital record and the computer advised us that the blood cultures were "no growth". Only after pursuing the lab were we able to find out that the lab *did* originally post a result saying that the blood cultures were growing Staph aureus (which the student saw) but the lab then realized it was posted in error and *replaced* it (without telling anybody) with the "no growth" result.

Can we therefore add, and agree, that the ability to edit progress notes, and the ability to review the audited (edited) notes, needs to be implemented together?

On 12-Aug-08, at 12:09 PM, James Busser wrote:

The best answer to the above may be to be able to express the EMR as it existed for a particular patient at a certain point in time. If a patient last saw a doctor at 2PM August 5, 2008 and if the issue becomes what the doctor found, what the doctor advised, and what the doctor did as of 2PM on August 5, 2008 then it should be possible to provide an EMR export that expresses what was in the record at that point in time.

In other words, if notes which were committed at 2PM were subsequently altered later on the same day, or at some later point in time when news of a complaint or adverse outcome surfaced, it would be important to be able to provide an EMR export that included the normally-hidden audited versions, along with time stamps.

The module could optionally exclude entries altered or added after a certain point in time however these could be important if they included legitimate clarifications and could be simply ignored by the reviewer when irrelevant. The module could also optionally limit the export to certain selected issues of interest.

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