The diagnosis entered by the doctor at the appointment is automatically overwritten by the diagnosis from the referral when selecting or editing the referral by registration.
B
Baranowska Iwona
In the current operation of the system, there is a situation where:
The diagnosis selected from the content of the referral automatically overwrites the diagnosis already entered by the doctor at the appointment!!!
This can happen when the registrar selects a referral associated with the visit or when the referral is edited/previewed again.
As a result, the diagnosis established by the specialist doctor in AOS is lost and replaced by information from the referral, even though the referral is preliminary and does not constitute a clinical diagnosis.
This causes m.in. risk of medical errors, problems with prescriptions (e.g. reimbursed drugs dependent on diagnosis, as in glaucoma), loss of doctors' trust in the system,
the possibility of incompatibility of medical records.
The diagnosis entered by the doctor during the appointment must be overriding and can never be automatically changed by the system.
Functional requirements (to be implemented/improved):
- The system cannot automatically replace the diagnosis of the visit based on the content of the referral either during registration or when editing the referral.
- If the system tries to enter a different diagnosis (for example, the user manually transfers it):
display the message:
“The diagnosis from the visit has already been established by the doctor. Are you sure you want to change it?”
- by default NO.
- Users with a registration role should not be able to:
overwriting the doctor's diagnosis,
or accidentally modify it when choosing a referral.
- If the diagnosis is changed manually the system should save:
who changed,
when,
from what value to what.
Autopilot
Merged in a post:
Disabling the change of the ICD-10 code after adding a referral.
M
Maciej Mydlak
The system should not automatically replace the ICD-10 code when a referral is added. I understand the mechanism of automatically loading the disease code from the referral. But in the case when, for various reasons, the referral was not connected and the appointment has already taken place and the doctor during the examination made a diagnosis and entered the ICD-10 code - then the disease code should not be changed by the function of adding a referral. Such data overwriting and interference with the patient's EDM should not take place.
You can apply a mechanism like this: as you add a referral and the ICD-10 code is empty then rewrite from the referral. If the field is not empty, you can add another one, but it should NEVER be overwritten. This leads to fraud and a different code is shown at the checkout than the one entered by the doctor in the documentation.