Concept of Operations: Relating to the introduction of a Personally Controlled Electronic Health Record System
4.2.2 Managing changes to clinical documents and correcting errors
Consistent with healthcare record management practices, clinical documents within a PCEHR will not be edited or deleted. Any changes will require a new version of the clinical document to be issued. If a document needs to be removed, it will not be deleted. It will be locked to prevent further access.
The PCEHR System treats the originating source system as the ‘source of truth’ and holder of the primary copy of the information. Any information held within a conformant repository is treated as a copy of information extracted from the source system. If a clinical document needs to be updated or amended, the source system must first be updated and a new version of the clinical document must be loaded into the relevant conformant repository.
The National Repositories Service and conformant repositories will be required to retain a history of previous versions of clinical documents for audit purposes.
Individuals and healthcare providers will be able to find clinical documents that have been recently amended using the index view (see Section 4.4.1). Access to previous versions of clinical documents is discussed below.
Requesting an error to be corrected within Clinical DocumentsIn the event that a clinical document contains incorrect information, the PCEHR System will support a number of processes to ensure that the information is corrected.
As mentioned above, if the information is incorrect, then the correction should be initiated within the source system and a new version of the clinical document should be issued to the PCEHR System.
The correction process is typically initiated by the healthcare organisation that supplied the document. Individuals or providers who wish to have a clinical document corrected should contact the healthcare organisation concerned to have the information corrected.
The PCEHR System Operator will help individuals with this process if they prefer not to approach the healthcare organisation directly.
Effective removal of clinical documentsIn the event that a clinical document has been loaded into a PCEHR and it should not be there, the PCEHR System will support a process around the ‘effective removal’ of clinical documents. Such events may occur if:
- Identification error: the healthcare organisation has inadvertently misidentified the individual in the clinical document.
- Clinical information error: the healthcare organisation has supplied incorrect information and the clinical document needs to be removed.
- Individual initiated removal: the individual did not wish the clinical document to be included in their PCEHR.
This process may be initiated by the individual or the healthcare organisation supplying the clinical document via the call centre or consumer portal.
If the clinical document has been loaded incorrectly into the wrong PCEHR or contains a clinical information error, the PCEHR System Operator will first effectively remove the clinical document from the PCEHR and work with the healthcare organisation supplying the clinical document to ensure that the correct information is loaded into the correct PCEHR. The healthcare organisation will take the responsibility to ensure any errors within their source systems are corrected.
If the individual requests a clinical document be ‘effectively removed’ from their PCEHR, the individual will be required to indicate that they understand the implications of its removal (namely that the clinical document will no longer be accessible via their PCEHR and this may mean that in the future the individual may not receive the benefits of having this information available via their PCEHR in future episodes of care).
A clinical document that has been ‘effectively removed’ from an individual’s PCEHR is not deleted. An effectively removed clinical document is no longer considered part of an individual’s PCEHR12 and is locked and a reason for removal is noted, preventing further access by an individual or their healthcare providers (including using emergency access). An effectively removed clinical document is only accessible to the PCEHR System Operator and may only be accessed for legal reasons.
If an individual elects to effectively remove a clinical document and later wishes for the clinical document to be restored within their PCEHR, they will need to contact the PCEHR System Operator.
Access to prior versions of clinical documentsThe PCEHR System Operator and Conformant repository operators will retain prior versions of clinical documents based on applicable retention policies (see section 4.2.4).
The PCEHR System will always ensure that individuals and healthcare providers are presented with the most recent version of a clinical document. If a prior version is available, individuals and healthcare providers will be given the option to access prior versions of clinical documents if they require. Any prior versions will be clearly marked as being a prior version.
12 While a clinical document may be effectively removed from an individual’s PCEHR, it may still be available from other sources.
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