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  • #31013

    ***UPDATE***
    Please note that the locking of Clinical Notes has been fully implemented since build 1058 (released on 26/08/10).


    One thing that could be a problem is in the clinical notes. For an insurance purpose you should not be able to modify previous entry in the sessions. At the moment it seems that the software allows you to do that even after stamping it. Is there any way of avoiding that? In the CO2005 it would just create another new section in the same SOAP notes in with staff name, date and time.
    By my understanding, this means that the notes can be tampered with without trace. Equivalent to keeping written records in pencil not pen – they don’t prove what a court would need them to prove, and therefore inadmissable as evidence. Worst case hypothetical scenario, the notes could be edited to suggest that such and such a test was done, or that such a treatment wasn’t actually given, potentially removing negligence from a case.

    Beyond that any concerns are only niggles and will probably be sorted out with familiarity; the admin side of the programme looks like a big step forwards from CO2005.

    Thanks for your help on this matter.

    #32274

    Support
    Keymaster

    HI – thanks for your post. We’ll be adding the ability to “lock down” clinical notes in an upcoming update.

    #32275

    Thank you.

    Could you tell me? will this be a switchable option, or the compulsory and unchangeable requirement that any solicitor will require if using the notes as evidence?

    #32276

    Support
    Keymaster

    As with CO2005 this will be an option that the administrator can configure.

    #32277

    Any idea when this will happen?
    I’m still using 2005, and will continue to do so until this is introduced. It’s a legal requirement if (gods forbid) I ever get sued

    #32278

    Hi We have a similar issue and it seems there are others.

    I have today been in touch with support who state that this is on a to-do list.
    a Possible date for update would be september.

    For us personally it would be ideal if clinical “session” notes could be saved, closed and Permanently locked.
    I just found this post by chance, I dont know if anyboy else has posted on forums requesting similar solutions?

    Could you guys possibly keep us posted as to how it all goes?

    Many thanks

    Dave

    #32279

    Support
    Keymaster

    Thanks for your post. Our ClinicOffice development schedule is currently as follows :-
    July : Email Module
    August : Online Diary Booking
    September : A whole raft of Clinical Note Enhancements

    Locking down the session notes will be implemented in an update sometime in September. The UPDATES PAGE on our website details all of the changes introduced into each new release :-
    http://pioneersoftware.co.uk/co-updates

    #32280

    Just coming back to this; quite honestly, “sometime in September” isn’t really good enough.
    For that matter – a switchable option is not really good enough either.

    And a quick point of order for Mur_Med, it’s not a case of “would be ideal” it’s a case of “legal necessity”, without which, no-one using the software has any legal clinical notes (unless also held as hard copy or audio recording) and thus, no legal defence should it ever be required. This is not just a nicety for our learned friends; it’s also (I believe) a requirement of the codes of conduct for most relevant professionals, thus any and every UK chiropractor, (for example,) will be in breach of GCC regulations by using v4.
    It’s is also a matter that I made Pioneer aware of very soon after launch via email, and again almost a year ago on the public forum ](*,)

    Currently, my 2005 version of clinic office is getting very bug-y; presumably because it hasn’t been updated in the last 18 months, yet windows has (this is my guess as to the source of the problem). It has now got to the point where it is impossible to actually use, as it crashes every 30 minutes or so (not very useful when a single consultation can last anything up to 90 minutes); hence I’m re-visiting this as a matter of urgency.
    I also fail to understand how or why it’s taken so long to get around to this problem which was reported to them approximately 18-24 months ago.
    I’ve not chased up as much as I probably should, but then, I don’t think it’s really my job to do so. I have, however, been using increasingly obvious language when I have chase up, as my point seems to be getting missed; I’m only going for a full-on assault now, as it’s threatening to affect me directly.

    Clinic Office: If you’re really going to take so long to push this through, could you at least give us an update for 2005 so I can continue to use that in the mean-time?

    #32281

    Support
    Keymaster

    Hi – thanks for your post.

    >> quite honestly, “sometime in September” isn’t really good enough.
    We prioritise development based primarily on requests from our customers. We have had over 100 requests from customers waiting for full Email functionality to be built into ClinicOffice and a similar number of online access to their ClinicOffice diary.

    By way of contrast, we have had 8 requests (including yours) for lockable notes, hence our development schedule is as previously stated :-

    July : Email Module
    August : Online Diary Booking
    September : A whole raft of Clinical Note Enhancements (including lockable notes)

    I am genuinely sorry if this is not good enough for you.

    >> For that matter – a switchable option is not really good enough either.
    ClinicOffice is used in HUNDREDS of clinics of varying disciplines. If we strictly enforce all notes being locked up without any option because one customer has demanded it, then we would (quite rightly) receive hundreds of complaints from many other customers.

    The decision to lock notes or not will therefore be configurable. Regardless of whether notes are locked or not, all records are date/time stamped which shows when they were created and when they were last updated.

    >> Currently, my 2005 version of clinic office is getting very bug-y;
    We’re not aware of any outstanding bugs in ClinicOffice 2005 and I’m unable to locate any error reports from you. Please can you send us error reports if/when a problem arises in CO2005?

    >> presumably because it hasn’t been updated in the last 18 months yet windows has
    We regularly test CO2005 with the latest Windows updates on Windows XP, Vista and Windows 7 and are not aware of any problems.

    >> it crashes every 30 minutes or so
    Please send us the error reports and we’ll look into it for you.

    #32282

    Only 8 people, including myself may have noticed this issue – that doesn’t mean that it’s a low priority. Let me make my perception plain.

    Currently, anybody (by which, I mean any and everybody) using this software will have no real defence if they ever end up in a court of law.
    Clinical notes, regardless of discipline, MUST be contemporary; and may not be alterable after the event. This is akin to keeping paper records in pencil. If anyone using this system gets sued for any reason, they will use their records of the event in their defence. If there is any chance that these notes have been altered after the event, they will be inadmissible as evidence.
    When I first pointed this out to pioneer by private email, soon after the release of V4, whoever responded agreed that this was indeed the case. It’s a matter or law, not a matter of personal preference. As such, I don’t care how many other people have noticed this.
    I’m not a legal expert, so I could be wrong in this – however, 2 solicitor friends who I’ve asked about this both agreed with my reasoning.

    If, however, there is something hidden away in the code of the programme that means all these changes ARE logged, saved, and stamped; but just not shown on the screen, then I back down entirely. If so, then I could have easily been made aware of this when I first raised the issue 2ish years ago (when it was agreed that exactly the problem I saw was the case); but never mind.

    As for my CO 2005 getting very bug-y, I could well be wrong in thinking it’s due to the lack of updates; in which case I apologise; however, we also have problems with outlook, which refuses to send emails, only to receive them – but that’s an entirely separate issue, just prevents me from sending error files.

    #32283

    Support
    Keymaster

    Thank you for your comments and for making your position very clear.

    Anytime that any record in COv4 is changed, the record is stamped with the date/time and the user who last updated the record. Access to this information can be retrieved by looking at the LAST UPDATED BY and LAST UPDATED ON fields which are common to all records in ClinicOffice.

    None the less, I’m very sorry that it has taken us a long time to get around to introducing this feature. Please be assured that it is scheduled to be done as soon as possible.

    #32284

    Thank you.
    So that means that it is already stamping and dating them, just out of sight? (or at least, out of sight on the not-up-to-date version on my computer? [hasn’t been kept up to date as it hasn’t been used, and at some stage a rebuild meant that we couldn’t update further without some keys, or something, can’t remember exactly what])

    If so, then that’s fine, and I apologise for my increasing levels of frustration; however a reply 1 or 2 years ago would have prevented all this (2 years ago being my private email, the reply to which said that my concerns were correct, and would be fixed ASAP; but which never visibly happened)

    edit: I think v4 has just been able to update itself, so that stumbling block is over now; I’ll just check the current visibility of editing on it

    edit2: ok, it has updated itself, it’s now on build 2057 which I think is right, but I can’t create a database to play on – I’ll just try a couple of other things before asking for help on that

    #32285

    Support
    Keymaster

    >> So that means that it is already stamping and dating them, just out of sight?
    If you look at the bottom of any record editor (e.g. a patient editor) there are date/time stamps showing when the record was created (and by whom) and when it was last updated (and by whom). This is true for all records in ClinicOffice, although for practical reasons not all are visible.

    >> I can’t create a database to play on – I’ll just try a couple of other things before asking for help on that
    If you’ve updated from a very old version, probably the best thing to do is to re-download the FULL installer again and re-install COv4. This will make 100% sure that all your files are updated. A link to the full download can be found on this page :-
    pioneersoftware.co.uk/co-updates

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