If health and social care continue to converge as is happening in the UK then the protocol of Soc Services is to also record things that may have been considered appropriate in principle but which the individual professional based on knowledge of the individual client circumstances chose explicitly NOT to do. This and the current discussion about 'signing' could have major ramifications on size and performance of records management systems. Any comments? Jean Roberts
st <dguest at zeeclor.mine.nu> writes >On Sat, 2002-09-14 at 21:03, Gerard Freriks wrote: >> Karsten, >> And others, >> >> >> What is your idea? >> >> - Can you agree with me that it is possible to proof that information was in >> a database at a certain time in most systems? >Certainly. That's what Horst's gnotary is about. >http://www.gnumed.net/gnotary/ > >> But most systems are unable to proof what was seen on a screen and signed >> before being committed to the record or sent to an other entity? >> - What are the consequences of the extreme but defendable position of >> TNO-PG? > >Gerard > >The logs would show that all the relevant patient data had been >downloaded to the client. I think it is asking too much of the process >to also verify that the doctor saw it on the screen, was in a fit state >to process the data and come to a logical conclusion. > >In my experience only the clinical note written on the day can concisely >log what data was processed to come to the clinical management plan. >Having pointers to the relevant data is helpful (e.g. see last entry 5 >July 2002; Dr Jones' letter, 26 February 2000, histopathology skin 14 >September 2002). I once thought a drag and drop hyperlink might be the >best way to do this but text entry is as efficient; just not as cool. > >Is this what you are trying to achieve? > >David > Phoenix Associates, 19 Church Meadow, Ipstones, Staffs, ST10 2LS UK email : jean at hcjean.demon.co.uk http://www.hcjean.demon.co.uk tel 07771 804472 or tel/fax+44 1538 266944 - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
