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Re: [Gnumed-devel] encounter edit before final save
From: |
James Busser |
Subject: |
Re: [Gnumed-devel] encounter edit before final save |
Date: |
Tue, 12 Aug 2008 13:23:39 -0700 |
On 11-Aug-08, at 1:24 AM, Jerzy Luszawski wrote:
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. Of course you can have each
procedure as
separate encounter: first part of the consultation, lab, radiology,
final
part of thnue consultation,but this will make it difficult to
analyse all
data as a whole, to generate a report from the consultation, and to
prepare
billing data. This is my point of view. Other may have different
needs and
different formal requirements to meet.
On the question of "caching" information prior to "finalizing" a
note, we do not have any method presently available, other than to
actually *write* the data into the back end.
As mentioned, only after an editing widget is written will it be
possible to edit the note in order to "finalize" it, if it was not
*already* final.
Even once an editing widget would be available, the first "writing"
would serve a dual function of "caching" as well as serving as the
"possible / assumed final". Only after a note would be edited would
the note become "relatively more final". Since any note will have the
capability to be corrected at a later date, we can never know that a
note will never change, however that is no matter. All that is
important to the person making the clinical decision is the state of
the information at the time that the decision is being made.
What *appears* needed seems to be a workflow tool in which to
distinguish, and be able to make selectively available, those notes
that we knew were incomplete, from those notes that we believed
complete.
This is sounding a lot like "you have unsigned lab results"
It sounds like people are arguing two levels of "save", one being
"cache / keep this information" and the other being called by some
"explicit save" by which they seem to mean "I am satisfied that this
is now in a form that can stand as a record of this encounter". To
me, this means the same as "sign" so we are potentially, in a multi-
threaded (multi-issue) encounter, talking about
- Clear vs Save vs Save and Sign
<the in-focus> issue SOAP note elements in this encounter, versus
- Clear vs Save vs Save and Sign
<all> issue SOAP note elements in this encounter
- [Gnumed-devel] Re: Gnumed-devel Digest, Vol 69, Issue 17, Rogerio Luz, 2008/08/08
- Re: [Gnumed-devel] Re: Gnumed-devel Digest, Vol 69, Issue 17, Karsten Hilbert, 2008/08/08
- Re: [Gnumed-devel] Re: Gnumed-devel Digest, Vol 69, Issue 17, Karsten Hilbert, 2008/08/08
- [Gnumed-devel] encounter edit before final save, Jerzy Luszawski, 2008/08/08
- Re: [Gnumed-devel] encounter edit before final save, Karsten Hilbert, 2008/08/15
Re: [Gnumed-devel] encounter edit before final save, Karsten Hilbert, 2008/08/11
- Re: [Gnumed-devel] encounter edit before final save, Rogerio Luz, 2008/08/11
- Re: [Gnumed-devel] encounter edit before final save, Karsten Hilbert, 2008/08/11
- Re: [Gnumed-devel] encounter edit before final save, James Busser, 2008/08/13
- Re: [Gnumed-devel] encounter edit before final save, Karsten Hilbert, 2008/08/13
- Re: [Gnumed-devel] encounter edit before final save, James Busser, 2008/08/13
- Re: [Gnumed-devel] encounter edit before final save, Karsten Hilbert, 2008/08/15