December 1, 2010 at 10:45 am #31165
I have a question about this new option ‘Allow editing of Clinical Notes’ . Obviously turning this off is absolutely essential from a legal viewpoint and we want to use this function, but from a practical viewpoint we have some difficulties with it.
The key issue for us is that if you start a report/letter and need to leave it for any reason before completion you can not return to edit them further. Whilst this is fine once a form is finished, you can’t for example start a discharge note in a spare 5 minutes and then come back to it or as is often the case two clinicians can’t add sections to a letter. I would suggest that a solution here would be a draft function (as for example is possible for this post) that could be used for reports/letters. Once no longer a draft it is then saved and locked so that further editing would not be possible (thus staisfying legal requirements).
Is this a possibility or is there already a way to do this?
I note from previous posts that CO does keep a record when a clinical note has been updated but does it save exactly how a record has been edited? If not then, as far as I understand from a legal viewpoint (speaking to a former head of the discplinary committee of the Royal College of Veterinary Surgeons), the records are useless.
Thanks for your assistanceDecember 2, 2010 at 3:12 pm #32609
>> you can’t for example start a discharge note in a spare 5 minutes and then come back to it
If you have turned off the option to “Allow editing of Clinical Notes” then when you go back to the record to comtinue typing notes, ClinicOffice simply inserts your new note as a new comment. All you would have to do is type in something like “[continued from previous note]” at the start to make it clear that the two notes are related.
Alternatively, you could turn off the “Allow editing of Clinical Notes” option and use the record locking feature to lock the record once you have completed the notes. That way you can go in and keep editing your notes up until the point where you have finished and then you LOCK the record.
>> I note from previous posts that CO does keep a record when a
>> clinical note has been updated but does it save exactly how a
>> record has been edited?
ClinicOffice stamps all records with a timestamp whenever they are edited but it does not log the changes made. The only way to do this would be to save duplicates of records every single time they are edited, which would bloat the database to a ridiculous extreme and greatly affect performance.
>> If not then, as far as I understand from a legal viewpoint (speaking to a
>> former head of the discplinary committee of the Royal College of Veterinary Surgeons),
>> the records are useless.
Let’s say I own a veterinary surgery and don’t use a computer so all my records are hand-written. I then get called before a disciplinary committee and present a hand-written sheet of A4 paper with my treatment notes and a date scrawled across the top of the piece of paper – how do you verify the validity of my handwitten date? What’s to say that I didn’t re-write the notes the night before? Would such notes not be equally “useless”?
Furthermore, if I did use a computer for electronic treatment records, what’s to stop me changing the system date/time of my computer in the BIOS, loading up my software and then entering some different notes? I could then print out these notes and they would be authentically time stamped with a completely false date. Is this not also “useless”?
Or what if I type in a load of completely fictitious notes (which get time-stamped), then I print the notes to a virtual printer driver, load the document into an image editor, adjust the time-stamps and print out the resulting document? Is that not also “useless”?
It is simply impossible to produce a computer system which is immune to abuse should someone be determined to do so. However, from our consultation with representatives from the various different professions who use ClinicOffice, we are happy that the security/auditing options which ClinicOffice provides are more than adequate and certainly a lot better than many other similar products.
I hope this helps to answer your question! 🙂
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