CCHIT - SOAP notes

[Sebastian Hilbert]

requirement:

Complete and sign off note.  Print a copy for the patient.

Print preview is acceptable for verification.
Note is retrieved from “draft” status, updates to note are captured, and note
accepts sign off.  System captures id
entity of the user and date/time of finalization.

AM 08.04 The system shall provide the ability to finalize a note, i.e. change
the status of the note from in progress to complete so that any subsequent
changes are recorded as such.
AM 29.02 The system shall provide the ability to generate reports consisting
of all or part of an individual patient’s medical record (e.g. patient
summary).
AM 30.02 The system shall provide the ability to generate hardcopy or
electronic output of part or all of the individual patient’s record.
Date and time must be system generated and recorded automatically.

...

Looks like they require the SOAP note can eb printed and handed to the
patient. I wonder if it is acceptable to copy and paste :-). Furthermore they
talk about a draft status of a SOAP note. That makes no sense. Since you have
the audit trail anything you put in is for real and becomes a draft once the
note is updated.

Sebastian


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[Karsten Hilbert]

On Sat, Nov 07, 2009 at 10:16:29PM +0100, Hilbert, Sebastian wrote:

> requirement:
>
> Complete and sign off note.  Print a copy for the patient.
>
> Print preview is acceptable for verification.
> Note is retrieved from “draft” status, updates to note are captured, and note
> accepts sign off.  System captures id
> entity of the user and date/time of finalization.
>
> AM 08.04 The system shall provide the ability to finalize a note, i.e. change
> the status of the note from in progress to complete so that any subsequent
> changes are recorded as such.

If *that* is the definition of "the note is signed" then we
already support that because for us *any* note is "signed"
in that sense: we record any and all modifications of a
note (including user ID and timestamp, of course).

"print a copy" - well, there's some support for exporting
the current note in Medistar import format - that can be
printed. Also, we support exporting the entire record as a
journal. That would include the note.

> AM 29.02 The system shall provide the ability to generate reports consisting
> of all or part of an individual patient’s medical record (e.g. patient
> summary).

We support reports but at a very low level. For
certification it is probably better to use OpenOffice or
Crystal Reports or Jasper Reports connecting to the GNUmed
database.

> AM 30.02 The system shall provide the ability to generate hardcopy or
> electronic output of part or all of the individual patient’s record.
> Date and time must be system generated and recorded automatically.

No problem :-)

> Looks like they require the SOAP note can eb printed and handed to the
> patient. I wonder if it is acceptable to copy and paste :-).

Sure !!

> Furthermore they
> talk about a draft status of a SOAP note. That makes no sense. Since you have
> the audit trail anything you put in is for real and becomes a draft once the
> note is updated.

It becomes "history", not "draft", but, yeah, once again we
are ahead of the requirement.

Karsten
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