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

From: James Busser
Subject: Re: access to review audits (was Re: [Gnumed-devel] encounter edit before final save)
Date: Wed, 13 Aug 2008 07:38:56 -0700

On Tue, Aug 12, 2008 at 12:59:33PM -0700, James Busser wrote:

trainee doctors... managing a patient under my care...
... *insisted*... Staph aureus growing in the patient's blood.

On 13-Aug-08, at 1:53 AM, Karsten Hilbert wrote:

A simple confirmative phone call to the lab
would resolve the situation.

Well, now I have had my laugh for the day ;-)

I am not sure I quite appreciate how this relates to editing narrative.

It was an indirect analogy being that a lab result was written into the record, was seen and acted on by a provider. The result was then changed in a way that gave no indication that a change had occurred and to make matters worse there was no way *within the record in question* to identify (audit) that the change had been made. It is not a question of a widget not having been written... the "original" was now "gone". As Rogerio indicated, this should NOT BE (allowed to be) POSSIBLE. The same is true with narrative. I am having trouble understanding that there would be a difference.

After all
one doesn't assume the trainee is involved in a deliberate
coverup of something.

No, the trainee could have been looking at someone else's record, and it may have been a simple mistake, or else an early indication of incompetence.

I declined, for the purpose of this thread, to get into whether it even made sense for the patient to be given antibiotics as it was not clear that there was a reason to suspect septicemia and the patient was not that sick and an argument could have been made to take another set of cultures even if antibiotics were to be started.

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