We need a more detailed audit log to find out what happened in a patient's chart. We need to be able to follow the path of everything that was done in the EMR. We need to know alerts that were triggered, what they said, when labs, XRs, etc. were acknowledged. We need to be able to see any comments that were added to those things when acknowledged. You should be able to follow every step. That is a true audit log.
The audit log also needs a patient name field. Having only the profile number and encounter number adds multiple steps to identify which patient is being accessed.
In addition to what is noted above, an audit trail would be great to include other items such as device name used to perform documentation.
Would also love for a tab to be available on the left chart panel in the EDIS module that keeps a real time, chronology snap shot of all aspects of the pt's care. Yes, this information can be obtained in various places of the chart but time is wasted to go into the multiple places to find it.
Our physicians have brought up issues with alerts as well. Once acknowledged, the alert is 'gone'. If an incorrect alert was acknowledged or the physician wants to go back and look at past alerts, there is no recourse. They were looking for a way to see these.
Here is the idea: Retain the alerts somewhere in the system. Call it the Alerts Retention Well. The alerts stay in the Well until they are deleted. Create Alerts rules. Have ability to create facility alert retention rules, roles based retention rules, and UBL retention rules.
EX:
Control = rule retention Facility = Role = UBL = allow multiple UBLs Line for delete alerts ______ days post discharge.
This way I can have a facility rule of delete after 15 days post discharge. I can have a physician role rule for delete after 20 days post discharge. I can have a UBL specific rule to delete Dr. Kenneth's after 45 days.
While the rules reside in the Well, have a screen so that folks can review acknowledged alerts. The alerts stay in the Well until deleted by the Alerts Rules outline above.
Of course, facility rule is for everyone unless they have a role rule. The role rule would be overridden by the UBL specific rule.
Agree 100% - the audit trail in a pt's record is an opportunity of improvement for Trubridge.
The audit log also needs a patient name field. Having only the profile number and encounter number adds multiple steps to identify which patient is being accessed.
This is also true for Patient Connect. Now we're using Patient Connect and no one, not even Thrive, can tell who is doing what in Patient Connect.
In addition to what is noted above, an audit trail would be great to include other items such as device name used to perform documentation.
Would also love for a tab to be available on the left chart panel in the EDIS module that keeps a real time, chronology snap shot of all aspects of the pt's care. Yes, this information can be obtained in various places of the chart but time is wasted to go into the multiple places to find it.
Our physicians have brought up issues with alerts as well. Once acknowledged, the alert is 'gone'. If an incorrect alert was acknowledged or the physician wants to go back and look at past alerts, there is no recourse. They were looking for a way to see these.
Here is the idea:
Retain the alerts somewhere in the system. Call it the Alerts Retention Well. The alerts stay in the Well until they are deleted.
Create Alerts rules.
Have ability to create facility alert retention rules, roles based retention rules, and UBL retention rules.
EX:
Control = rule retention
Facility =
Role =
UBL = allow multiple UBLs
Line for delete alerts ______ days post discharge.
This way I can have a facility rule of delete after 15 days post discharge.
I can have a physician role rule for delete after 20 days post discharge.
I can have a UBL specific rule to delete Dr. Kenneth's after 45 days.
While the rules reside in the Well, have a screen so that folks can review acknowledged alerts. The alerts stay in the Well until deleted by the Alerts Rules outline above.
Of course, facility rule is for everyone unless they have a role rule. The role rule would be overridden by the UBL specific rule.
Current audit logs are very complicated unless you really know the database.