Medical record locking

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Development Project Status: Completed

Total cost estimate (ex-Tax): 
$6130
Due date for completion of this stage: 
07/10/2015
Release: 
1.9
Current Percentage Funded: 
82.00%
Project funding: 

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Project description: 

Overview

This project will add support to lock medical records 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 will support locking:

  • Note
  • Addendum (see below)
  • Weight
  • Medication
  • Attachment
  • Form
  • Image
  • Letter
  • Investigation

Locking

Medical record locking will be enabled by a new practice level configuration option Medical Record Lock Interval. This will specify a period and units, e.g 24 hours or 1 week. If blank, locking will be disabled.

Medical records will be locked by setting their status to Finalised. This will be 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 - interval

where:

  • Start Time = the date/time when the record was created
  • now = the current date/time
  • interval = the Medical Record Lock Interval

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 and Attachment 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.  See OVPMS-1309
  • Investigation records can have:
    • results attached
    • select attributes changed (see Investigation Changes below)

Addendum Record

To support changes to Notes and Medication records that have been locked, a new Addendum record will be provided. This is a type of note that:

  • is added to an existing Note or Medication
  • 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.

Investigation Changes

Status

The patient Investigation record has a status field which is incompatible with the proposed locking mechanism i.e. its status may currently be one of:

  • In Progress
  • Received
  • Completed
  • Cancelled
  • Preliminary
  • Final

This will be changed so that the status field may be one of:

  • In Progress
  • Cancelled
  • Finalised

A new field, Result Status, will be added which may be one of:

  • Pending - the order is yet to be submitted
  • Sent - the order has been submitted
  • Preliminary - preliminary results have been received. This will be the status the Document Loader uses whenever it attaches a document
  • Final - final results have been received. This must be set by users

The Completed and Received statuses will be dropped.

This will require a change to Workflow - Investigations workspace, to support querying by Result Status instead of Status.

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 should create a new version, if a report has already been attached.
  • The Reviewed flag needs to be editable
  • The Result Status needs to be editable

All other fields should be read-only. It should not be possible to replace an existing Report, nor edit past versions.

Editing Records

Prior to editing an In Progress medical record, a check will be 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.

Archetype Changes 

  • The Weight, Note and Medication archetypes, need a read-only, hidden status node with possible values:
    • In Progress
    • Finalised
  • A new Addendum archetype is required
  • Each of the record types currently allow their date to be changed. These dates will need to be made read-only, as they will be used to determine when the record is locked.

Reporting Changes

The following reports need to be updated to support the Addendum record:

  • Medical Records
  • Problems
  • Patient History Search

Migration

Existing investigations need to be migrated, in order to support the new Result  Status. Any investigation with:

  • Completed status will be set to Finalised, and the Order Status set to Final
  • Received status will be set to In Progress, and the Order Status set to Sent

 

Comments

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Re: Medical record locking

Hi,

Already emailed to TimA but put here for records sake... 

The spec is a good start (though there needs to be a log of when it is turned on and off and a determination of what the behavior is when it is turned on (i.e. do records >24 hours old lock, do records lock 24 hours after locking is turned on). What happens once the option is deselected... Do records unlock or remain locked, etc.

Re: Medical record locking

I agree about needing the log to document when the controls are adjusted. 

I would suggest that when turned on, all records fitting the criteria are automatically locked. If you are defining the period as 24 hours, any record greater than 24 hours old locks. 

When off, all records should remain locked. 

Is a feature allowing addendums to be added to locked items feasible? The original record cannot be edited, but a secondary note attached for the first can be created to annotate any corrections.

Thanks, Alan

Re: Medical record locking

The proposed locking is just a switch; you turn the switch on and any record created 24 hours (or whatever) previously cannot be edited. You turn the switch off and you regain the ability to edit these records. In this approach, the records themselves don't change to indicate they have been locked.

Your proposal to keep existing records locked even if the Medical Record Lock Interval is disabled would require updates to the records themselves. This would need to be done by a background task that periodically runs to set a flag on records to indicate that they are locked.

I think this is unnecessary. The ability to enable/disable locking is restricted to administrators. With the Create/Update user information project, you would be able to detect records that have been changed after locking has been disabled by comparing the update time with the create time. E.g. if they are greater than 24 hours, then the record has been changed while locking was disabled, or the lock period was extended.

How would you like addendums to be presented in the user interface?

What would you like to be able to attach addendums to?

Re: Medical record locking

Understood on the locking part but if the records can be edited once unlocked, we would have to have an audit trail that showed all edits made, who made them and when they were made. This is a legal issue here in the states. If we were only able to show that edits were made but not show what was changed, this could put us at greater risk. 

Re: addendums, Medical notes specifically. 

If my memory serves me correct, once a record is locked in Avimark the text it contained could not be edited, but an addendum could be added at the bottom with its own timestamp and note about who created it. 

It looked something vaguely like this:

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.  

Addendum saved on 10/20/15 at 2:37pm by Alan 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. 

 

Re: Medical record locking

Sorry, my reply was added twice .

 

Re: Medical record locking

Given this is being suggested in part to ensure medical records are legally defensible I would invite some comment from the USA crowd as to the wisdom of making medical records editable again if the switch is turned off. Would this be an issue in that jurisdiction?

In my opinion no-one, not even admins, should be allowed to make medical records editable once they are locked. This opens us up to issues. Locked should mean locked... 

Re: Medical record locking

OK - it sounds like all medical records need to have a status that allows them to be either In Progress (editable), or Finalised (not editable).

A background task would periodically go through all In Progress records that need to be locked based on the locking interval, and set their status to Finalised.

It would still be possible to update finalised records as per the Exceptions listed above.

Of the records to be locked, only Note, Weight and Medication don't have a status. Investigation uses the status for multiple purposes, i.e. its status can be:

  • In Progress
  • Received
  • Completed
  • Cancelled
  • Preliminary
  • Final

The "Received", "Preliminary" and "Final" would need to be moved to a separate field (unless noone uses them).

With regards to addendums, I think we would support this via a new record type, that links to the note being added to.

In the history you would see:

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

Addendums would be displayed in increasing chronological order. There wouldn't be a facility to add an addendum to an addendum. You would add it to the note, and it would display after any other earlier ones.

 

Re: Medical record locking

Tim, thanks for working on this with us. Can you clarify one point in your last post? Will medications be locked, or is that still an exception? Locking the medication records is equally as important is the medical notes.

Thanks, Alan

Re: Medical record locking

Any locked record linked to an unfinalised invoice (medication, investigation or document) could still be changed via the invoice. These same records would not be editable via history.

i.e via the invoice you would be able to:

  • change medication or investigation details
  • delete charge items with linked medication, investigations or documents. This deletes the records as well

If you reverse the invoice, the records will be unlinked from the patient history, but will still be present in the database for reporting purposes. See OVPMS-1309 for the background to this. There is currently no report for these records, but one could be developed.

Re: Medical record locking

Got it. 

Any ideas on pricing so I can show it to the uppers?

Have a great weekend. 

Alan

Re: Medical record locking

I'll try and have it costed by the end of the week. I still need to work out some of the details regarding how investigations should be handled.

-Tim

Re: Medical record locking

Thanks Tim. 

Re: Medical record locking

The specification as it stands allows users and the document loader to add results to investigations and patient document acts indefinitely. If there are existing results, these will be versioned. Should there be a point where you can no longer attach results to investigations/patient documents?

Should Addendum be able to be added to other patient records other than Note?

Re: Medical record locking

As long as they are versioned/archived, I think being unrestricted as to when new files can be attached is fine. 

Medications would be useful. 

Re: Medical record locking

Tim, we will pledge the first $2,000 for the project.

Alan

Re: Medical record locking

Thanks for getting the funding on this project started Alan.

Re: Medical record locking

Two of our staunchest supporters have provided a further $3,000  funding for this project. Thank you!

Re: Medical record locking

Good morning Tim. 

I mentioned it to Tony so hopefully word has made it to you already. The locking of investigations seems to be buggy. It doesn't allow users to change the status, the field is grayed out and reads "In Progress". If we need to change a setting, can you please let me know?

Thanks, Alan

Re: Medical record locking

At this stage, the status is not editable. It is updated to:

  • Finalised by the Medical Record Locker
  • Cancelled, either by deleting the invoice item, or via the HL7 laboratory service

There is a bug in the Workflow - Investigations where setting the Order Status to Incomplete includes investigations that have been Reviewed. These should be excluded. This was fixed in revision 7126.

-Tim

Re: Medical record locking

Tim, we have been using this for a while now and things have been going well. 

Question: One of the next hospitals we are thinking about adding is a 24 facility. Is it possible to add an additional criteria that a pet must be checked out before the record locks? I am envisioning a pet checking, staying a couple of days in recovery and having to either keep amending their initial notes or having multiple medical notes for a single visit because they intermittently lock during the visit. 

Thanks, ALan

Re: Medical record locking

Hi Alan,

My opinion is for multiple day visits ther should be multiple notes as they need to be dated and also potentially added by a different clinician.  Most would not keep ammending the one note record for the whole period of the stay ?? 

Cheers Tony

Re: Medical record locking

Hi Alan,

I run a 24 hour facility. I can tell you that inpatients require multiple notes. If for no other reason than you very very quickly run out of room in one note.

Bigger issue in 24 hour facility is inadvertent finalisation (finalizalion :) of invoices/visits.

This is not to mention the disaster of someone accidentally deleting a single note that contains all the records for 10 days of treatments... :) Multiple notes. Works well. Can show you what we do if you like.

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