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[Gnumed-devel] Editing / altering / changing clinical records in GNUmed

From: Jim Busser
Subject: [Gnumed-devel] Editing / altering / changing clinical records in GNUmed (audit logs)
Date: Tue, 28 Jun 2011 21:20:01 -0700

Sometimes people new to the list get concerned when they see that GNUmed makes 
it possible to alter "clinical" entries mainly to prevent the re-use of 
information that is later determined was incorrect and which (left that way) 

- make it unclear that the mistake was recognized, and

- may, if left that way, endanger the patient or even just confuse the care

While it is true that late entries can be "added", this creates the possibility 
(risk) that action could be taken based on the incorrect version (i.e. the 
correction may not be seen or understood).

Doctors reading this post may think

        "Yes, but it is illegal to make such changes."

Generally-speaking, it is not the change that is illegal… it is the action of 
removing or altering the original. Be assured, GNUmed does NOT do this with 
clinical data. All alterations to clinically-meaningful information are built 
into GNUmed's audit system which I can illustrate.

Today, I changed an item in the "Waiting list" which I have been using for 
storage of some of my "ToDos".

As "any-doc" (because I am not yet fully in "production"), I had needed to 
follow up on my "patient 19" 's thyroid test results. After inputting my 
progress note, I needed a way to remember to phone their GP tomorrow, so 
instead of creating a new "Waiting list" item I simply edited the existing one.

But… what if it should later be important to know what that item originally 
said? Not to worry. By design, while the GNUmed audit tables cannot be queried 
by "regular" users, they can with gm-dbo (or postgres) permissions.

From the command line, I did as below and used the pgsql tool. I only 
reformatted (for email) what was originally one row, into two, to demonstrate 
this. The original row (from June 24th) is shown first, and below it the June 
28th altered version. See? It's all there.

-- Jim

./psql -d gnumed_v15 -U gm-dbo

SELECT lwl.modified_by, lwl.modified_when, lwl.comment, \
cwl.modified_by, cwl.modified_when, cwl.comment \
FROM audit.log_waiting_list lwl \
INNER JOIN clin.waiting_list cwl \
ON lwl.fk_patient=cwl.fk_patient \
WHERE lwl.fk_patient = 19 ;

 modified_by |       modified_when           |              comment            |
 any-doc     | 2011-06-24 17:11:46.321-07    | thyroid scan results June 21    |
 any-doc     | 2011-06-28 17:36:34.032364-07 | call FamilyMdName 604-123-4567  |

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