Medical Record Locking

Complete

Patient medical records are automatically locked to prevent them being edited, after a period of time. 

Once locked, a record may not be not edited nor deleted except in specific circumstances - see Exceptions below.

The following records support locking:

  • Note
  • Addendum
  • Weight
  • Medication
  • Attachment
  • Form
  • Image
  • Letter
  • Investigation

Medical record locking is enabled by the practice level configuration option Record Lock Period. This defaults to 24 hours. If set to zero, locking is disabled.
 

Medical records are locked by setting their status to Finalised. This is done automatically by a background task that runs periodically to set the status on all In Progress or Completed  medical records with:

Start Time < now - period

where:

  • Start Time = the date/time when the record was created
  • now = the current date/time
  • period = the Record Lock Period

Exceptions

There are a number of exceptions to the locking rule:

  • Medication, investigation and document records linked to an invoice may be edited or removed via the invoice, until the invoice is finalised
  • Investigation, Attachment, Image and Letter records can be updated via the Document Loader
  • Medication, Investigation,  and document records can be unlinked from the patient history if the invoice is reversed.
  • Investigation records can have:
    • results attached
    • their Order Status changed

Addendum Record

To support changes to Notes and Medication records that have been locked, an Addendum record can be added. This is displayed after the record in the history that it annotates

A record can have multiple Addendum records. They are displayed in increasing chronological order e.g.

20/10/2015 - Consultation - J Smith [Completed] (8 years)
  20/10/2015 Note      J Smith    S: P presents for a 5-6 day history of rear limb weakness and crying out in pain in the mornings. 
                                  O: PE unremarkable.  
                                  A: Differentials: IVDD, vascular event, etc
                                  P:  Treat symptomatically for now with prednisone and methocarbamol.
  23/10/2015 Addendum   A Bern    Above note was saved incomplete: O has tramadol at home and told o to continue to give tramadol 
                                  for the next 5-7 days.  Recheck in 7-10 days if does not resolve.
  24/10/2015 Addendum   A Bern    Another addendum to the note
  20/10/2015 Medication J Smith   Amoxil Tablets 200mg Qty: 1

An Addendum may only be created if the selected record is a Note or Medication. Adding an Addendum to another Addendum is not supported as it may make the chronology unclear.

Auditing

The ability to enable or disable locking is available to administrators. A new Audit Message will be logged to Workflow - Messaging when locking is changed. e.g.

1/10/2015 10:00 - Medical Record Locking Interval set to 1 week by admin

or:

1/10/2015 10:32 - Medical Record Locking was disabled by admin

This message may be read, but not deleted.

Post Locking updates

Investigations need to support some updates after they have been locked:

  • Reports need to be able to be added. Adding a report creates a new version, if a report has already been attached.
  • The Order Status is editable

All other fields are read-only.

Editing Records

Prior to editing an In Progress medical record, a check is performed to ensure that it may still be edited based on the locking criteria. This is required as the background task may not have got round to change its status to Finalised.