Quoting Richard Terry <[EMAIL PROTECTED]>: > ...editing a progress note from another user SHOULD > NEVER BE ALLOWED... > Why would you allow that.
> I write my clinical notes. If I make changes within my current session, > those changes should make up the medical record (not the bits I changed which > should not be recorded). The record should not be committed to the database > until I (the doctor) have decided that they should by hitting the save key, > or the consultation is over. There can be a useful distinction, if you have to interrupt what you are doing (e.g. leave the office in an emergency) between "Save" meaning "I do not want to lose what I have put in so far", and "Sign" meaning "I am satisfied that what I have written is accurate and sufficient". Related to this, Horst had way back made a proposal (post 0.1) concerning "limboed" items which I captured on the wiki with a link from the DevelopmentReference page > If I the doctor, want to then amend/change, then this change is added > sequentially to the record. If someone else wants to add/change, it is added > sequentially to the record. I do have a question here... what if it is determined that information contained within a note is *wrong*? If that error remains available, and if there is no indication to the person viewing that it is *wrong*, that viewing person could be interrupted before getting to the amendment. Maybe the "nicest" (but difficult) solution would be to be able to mark up text inside a note, or else to insert a link or reference alerting / anchoring to a comment located inside a later note. Alternatively a uniform way that the GUI (through all clinical middleware?) be able to inform the user (visually and/or interactively when choosing to view the content of a note, value etc.) that an audit trail exists for the item. _______________________________________________ Gnumed-devel mailing list [email protected] http://lists.gnu.org/mailman/listinfo/gnumed-devel
