Medical Record Notes (MRNs) - Privs, Creating/Editing/Deleting

Overview

This document is meant to help provide information regarding how SpecVet treats Medical Record Notes, how/when they can be edited, etc. Specifically we are seeking to answer the following question: 

What are the rules / features of how Medical Records Notes (MRNs) are edited?  
When do they get “Locked”?  
Who can edit them, and for how long? 
How are edits handled, logged etc.? 

Background

Medical Record Status

  • MRNs belong to a VISIT, and a Visit has a Medical Record (MedRec) Status which is either OPEN or CLOSED.
    • A Visit - even if discharged - can remain to have it’s MedRec Status remain Open, which allows for the staff to complete their records after the patient has been discharged. 
  • Whether or not the Visit’s MedRec Status is OPEN or CLOSED determines the behavior within SpecVet for what users are able to do. 
    • In SpecVet, we do not make a differentiation between Creating a MRN versus Editing a MRN -  if you have the priv to create, you can also edit & delete. 

Privileges / MRN Priv Groups

  • MRNs are assigned to a specific “MRN Priv Group” which control the actions (which Privs are needed) that users are allowed. 
    • These groups were built so that you don’t have to setup Privs for each individual MRN type. Normally, clinics have 4 different MRN Priv Groups: General Medical Record Notes; Reports; Communications; Internal Notes. 
  • Furthermore, when assigning Privs to a user, for the MRNs, you can indicate for Privs within that Priv Group whether or not the user has the ability to Create/Edit MRNs based upon wither the MedRec Status is set to OPEN vs CLOSED; or to act as an ADMIN user

In the example above, the user is able to Create/Edit/Delete:

General MRNs only when the Visit’s MedRec Status is OPEN
Reports only when the Visit’s MedRec Status is OPEN
Comm when the Visit’s MedRec Status is either OPEN or CLOSED
Internal at any time, as the user is flagged as an Admin (Admin allows full access).

System Setup/Settings

  • From the SETUP>SYSTEM PREFERENCES you will find the General Preferences tab which contains a HOUR value for how long Medical Record Notes stay editable.
SpecVet Actions

Check to see if the user has the proper priv based upon: