We had a problem which is readily repeated by the nature of how OpenEMR works. If someone simply misses that they have somehow switched Active Patient, any notes written will be associated with that patient instead of the correct one. Unfortunately, the info contained therein can become a HIPAA violation unless the note can be removed or cleaned of the concerning info.
There is no "Delete" for notes, which itself deviates from the "feel" elsewhere. And trials with deleting within the Admin - Database area using the BROWSE to find the note caused the next note created to insert at that spot in the database, and subsequent additions continue from there, instead of adding to the database end. I am nervous about the logical implications of that.
But trying to simply substitute text for the offending text leaving the original note storage location still results in subsequent notes inserting from there as well.
I do not see any way to deal with this which is any different in 3.0 from our active 2.9.1dev in Windows. Anybody got any solution, or know for a FACT that the insert is not a problem (I tried a few and they seemed to view correctly, but that is far from exhaustive testing nor sufficient for my skepticism).
present it for preview like it is done for printing etc with patient name highlighted before the save button is active.
need a final signature to avoid further tempering with the note.
the deletion of signed note in emrs is done by adding addendum to the note while leaving the incorrect note in its current location/file like it is done for a paper note.
There are two types of standard notes in OpenEMR:
1) Office notes
2) Patient notes
The Office notes are visible to anyone. I imagine they should not contain any patient specific info.
The Patient notes are tied to a single patient. While there is no -delete- ability you can append a note indicating the prior note should be disregarded. I can see how this might turn into a HIPAA violation if the note expresses some confidential information and appears in the wrong client.
You can delete a specific note from the database table ‘pnotes’. Once deleted there, it will never reappear. So wield this power very carefully.
A ‘delete’ button could be added to the interface for users with full admin permissions. However we need to be sure the action is logged. Also, does it violate any regulations if a note is destroyed forever?
I also want to point out that Patient Notes are different from Encounter Notes. If you need to create a note that is specific to an encounter then you should be putting that information into a form associated with an encounter. Not in the more general Patient Notes.
So, anyone, please speak up regarding the potential legal/ethical trouble that could arise if a patient note was deleted from the system.
I believe we must have the ability to delete a note, but that the deletion should be limited to the original author or a full administrator. I cannot see how a deletion with those restraints would violate anything, since those same capabilities exist already for deletion of a patient and for other info within OpenEMR, so that would merely assure consistent behavior.
I did some testing and am concerned about how things worked. I could modify, append, or remove text with the phpMyAdmin functions in Admin - Databases, so the physical capability already exists. But that causes the subsequent adds of new notes to be inserted in the database immediately following the edited record, instead of at the end as i would expect. I am concerned that some undesired behavior will be caused by that, and have no way of knowing what I could test to get a comfort zone for that.
As you suggest, it is probably a good idea to have some notation that office notes are visible to all (if that isn’t self evident already) while patient notes must be limited by ACL. Thanks.
Signature is something which has been a sticky point for my client all along, and for which I see no real solution just yet.
I am not comfortable with even the idea of a signature "submit", since it is unlikely that she would have submitted as she did had she realized she had the wrong patient record. That WILL happen again, although I commend the inclusion of the patient name in the blue bar in ver 3. But adding another step will not prevent the problem, while it WILL add work and complexity. I am sure you all have complaints about the fact that failure to "save" causes all kinds of problems already. Adding another omission opportunity is pointless.
Might I suggest that we actually create the ability to have a scanned signature in the form of a GIF which can be pasted by the author with a "hotkey" at any time, and would be a simple HTML - like link to that GIF embedded within the text? Creating it would be simple (in Windows at least, although I have to believe such a utility exists in Unix/Linux as well) with the Paintbrush, or with a scanned signature using any photo editor. I would suggest the signature GIFs be associated with a specific USER, and stored in the …/custom directory. That hotkey should be universal throughout OpenEMR, and therefore not adjustable, so it does that always and for whichever user is logged. Ideally that would display and print with anything to which it was pasted.
yes, although is not simple because it takes a bunch of different technologies put together, such as svg, javascript, php (or other back-end), and tex,
for a system I developed (and still working on it), I use an SVG script that adds the ability to sign in the browser,
this generates a form field that gets populated via javascript with the generated SVG string, the server then receives the svg string, and creates a ps graphic file,
then that ps graphic file gets embedded on a LaTex document and the LaTex document gets parsed into dvi and then into a pdf, the result is a “piece of paper” with a signature that was captured from the browser
I’ll send the primer to Rod,
Your comment works fine in a paper world. Exactly how does one do that in an e-world? There is no EDIT to allow even a comment at the end of a note within OpenEMR directly, and are we really sure we want to have people making direct adjustments to the database external to OpenEMR? I shudder at the risks to the databases.
There ought to be a better way. And I reiterate the issue which drove the question in the first place - what happens when we have info for one patient which gets put into the record of another? Almost EVERY other piece of data has an edit EXCEPT Notes. In a paper world we would simply remove and replace the paper from the wrong folder. We MUST have that similar capability in the e-world or we replace one HIPAA violation with another. And I think having another patient’s info in my record is a far worse violation than a signed note saying I made a mistake, don’t you?
I use the "speech" dictation "form" to enter text. These notes can be deleted, however, it the "encounter" (date and chief complaint) can not be deleted.
Joe, why not simply add a note on the same day as the wrong encounter and explain the the note was in error just like one would do in a paper chart?
I agree with Joe. We have to balance the sanctity of any entry in the record with the utility of the record, else we shoot ourselves in the foot. My understanding of the legal/ethical requirement is that the record need not be indelible as long as there is a log of who made an edit and when it was made.
Why if I can click on the SOAP for an encounter and delete what I previously wrote there can I not do the same for Notes?
This seems to be another inconsistency between program elements which should be corrected.
And again, the REAL problem here is that it may not be remembered years from now that there is someone else’s sensitive info contained in this patient’s record, which can then be transmitted to someone who DOES have a Consent form for this patient, but NOT for the patient with the errant inclusion, so we violate HIPAA there. And saying so in the record is NOT a solution to me.
I’ve assigned it to myself and will do the development today or tomorrow. It seems the legality does not play much of a part here. However, to cover our butts, the software will never delete the data. Instead it will mark the notes as deleted and never show them on the UI. To see a deleted note you must dig into the MySQL table.
I believe this is very good compromise and something that drug makers, such as Pfizer, use in the code all the time. I worked there for 5 years as a developer and never once were we allowed to make data disappear forever. This made the overall size of the database larger and perhaps affected its performance too. But I don’t think any OpenEMR installation has that problem yet.
That sounds great. When you say delete a note, are you referring to a specific form or to all encounter forms in general? Or, whole encounters? I know we already have a feature for deleting encounters, but it seems like it actually deletes the data and then logs the event. It should do as you say, not delete anything, just mark it as deleted.
If you are referring to deleting form entries, can you do it in a way that individual forms do not have to be altered? Maybe at the level of the forms table?
Also, re-assigning data entered for the wrong patient should be implemented carefully. Maybe it should not be deleted from the original chart, just copied. Or, at least make a detailed log entry regarding where the note came from and where it is going. Users might use re-assigning as a way to delete by sending notes to a dummy chart.
I have been traveling and now back in action. Thanks to Brady I could install openEMR after selecting proper collation ( Language - Spanich Ci). We filled in a few dummy patient data to check the functions and learn. After we enterd the data, I tried to look at the pctients list but the names do not appear there. It is empty. When I put either the first or last name in the Find by name field, I get the patient details. Am I doing something wrong.
I have been traveling and now back in action. Thanks to Brady I could install openEMR after selecting proper collation ( Language - Spanich Ci). We filled in a few dummy patient data to check the functions and learn. After we enterd the data, I tried to look at the pctients list but the names do not appear there. It is empty. When I put either the first or last name in the Find by name field, I get the patient details. Am I doing something wrong.
I like the way Jason approaches it, and I think that should be our standard. I would add that ONLY the original author or an administrator should be able to DELETE anything, and then I agree it should simply remove it from careless accessibility.
I prefer the idea of telling users who inadvertently mixed data to create a new note using click & paste, then DELETE the whole prior note. That saves any problems with mixing edit and delete.
Jason; How soon can I get a patch to help my wife, if only to get some peace (spell as you wish
I’ve committed the changes to CVS for this feature. Here’s a summary:
- Patient notes can be deleted
- Only an Admin or the note author can delete a note
- Notes are marked ‘deleted’ in the database but never really erased
- ‘deleted’ notes will never appear to the user through the GUI
- notes can be ‘undeleted’ using phpMyAdmin and toggled the note’s ‘deleted’ flag in the ‘pnotes’ table
"Nothing should be deleted or altered. Errors should be crossed out with a single line and initialed. "
If a note has been entered erroneously, into the wrong patient’s file, then there should be a logged delete capability…just as Jason has set up.
However, if a deletion or edit is desired in any given patient’s file then, "Nothing should be deleted or altered. Errors should be crossed out with a single line and initialed. "
Most emr software that I have used have have this feature. I think that there should be no ability to delete or edit a pt note, soap, etc. unless the note remains…lined out.
Are there not some legal/ethical/audit concerns if there remains the ability to change pt notes/ soaps / etc. without leaving a ‘paper trail’
