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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: Fri, 15 Aug 2008 16:40:04 +0200
User-agent: Mutt/1.5.18 (2008-05-17)

On Mon, Aug 11, 2008 at 10:24:23AM +0200, Jerzy Luszawski wrote:

> Data entered but not signed-off should be regarded as unreliable, so there is 
> no use of them for anybody,

I shall challenge that assertion. Unsigned notes are just
that - unsigned.

> The more likely scenario is that a patient comes in, the consultation starts, 
> then the patient is sent to, say, ECG or x-ray, in this time next patients 
> come in, then the first one returns, and the natural way would be to 
> continue "paused" consultation.
That's how GNUmed works.

> Of course you can have each procedure as 
> separate encounter: first part of the consultation, lab, radiology, final 
> part of thnue consultation,
Nah, that wouldn't be desirable.

> In my opinion entering "progress note" is slightly different from eg. 
> entering 
> lab results or attaching documents. Lab results or radiology reports are 
> finished, complete before they reach clinician. So entering them is only a 
> matter of storing a copy, Most of the time they can be verified by others 
> against "original" report. "Progress note" is the first, original data entry. 
You are right. That's an interesting observation. Keep up
the good thinking.

> No result leaves a lab without sign-off. Similary, no progress note should be 
> made available to others without explicit save
But then I don't understand your reasoning - why force
progress notes to behave the same way if they are something
(slightly) different ?

If progress notes are known to be "original data entry" they
should be treated as such by any responsible, reading
clinician. Explicit signing can be a nice addition.

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