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[Gnumed-devel] CCHIT - SOAP notes

From: Sebastian Hilbert
Subject: [Gnumed-devel] CCHIT - SOAP notes
Date: Sat, 7 Nov 2009 22:16:29 +0100
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Complete and sign off note.  Print a copy for the patient.

Print preview is acceptable for verification.
Note is retrieved from “draft” status, updates to note are captured, and note 
accepts sign off.  System captures id
entity of the user and date/time of finalization.

AM 08.04        The system shall provide the ability to finalize a note, i.e. 
the status of the note from in progress to complete so that any subsequent 
changes are recorded as such.
AM 29.02        The system shall provide the ability to generate reports 
of all or part of an individual patient’s medical record (e.g. patient 
AM 30.02        The system shall provide the ability to generate hardcopy or 
electronic output of part or all of the individual patient’s record.
Date and time must be system generated and recorded automatically.


Looks like they require the SOAP note can eb printed and handed to the 
patient. I wonder if it is acceptable to copy and paste :-). Furthermore they 
talk about a draft status of a SOAP note. That makes no sense. Since you have 
the audit trail anything you put in is for real and becomes a draft once the 
note is updated.


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