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  1. Other Specification Feedback
  2. OTHER-2365

Unclear in guidance document if the consultation note and the physician's response is saved in EMR

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    • Icon: Change Request Change Request
    • Resolution: Persuasive
    • Icon: Highest Highest
    • Pharmacist Consultation Note (OTHER)
    • 1.0
    • Pharmacy
    • Informative
    • Use cases
    • 4.1
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      Added section 3.2 Document Retention and Management

      Pharmacist Consultation Notes should be retained and managed the same as all other patient care and clinical notes. The authoring system, as the system of record, must retain and preserve the document and all revisions.  Receiving systems should also retain and preserve the document.  All systems should maintain the association between the document and the target patient (i.e., the patient’s record).  Access logging, security, and retention policies should be defined and adhered to by the responsible organization(s) in light of business, legal, and regulatory requirements.

       

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      Added section 3.2 Document Retention and Management Pharmacist Consultation Notes should be retained and managed the same as all other patient care and clinical notes. The authoring system, as the system of record, must retain and preserve the document and all revisions.  Receiving systems should also retain and preserve the document.  All systems should maintain the association between the document and the target patient (i.e., the patient’s record).  Access logging, security, and retention policies should be defined and adhered to by the responsible organization(s) in light of business, legal, and regulatory requirements.  
    • Scott Robertson / Shelly Spiro : 11-0-0
    • Clarification
    • Non-substantive
    • 1.0

    Description

      Global comment that may apply in more locations than just 4.1 - It's not entirely clear from the text or the diagrams if the consultation note and the physician's response is saved to the EMR – does this become part of the patient's record? Or is it just maintained in the LTPAC pharmacist system? Please provide additional language in this guidance document regarding data retention if possible.

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            smrobertson Scott M. Robertson
            tscheid86 Tyler Scheid
            Celine Lefebvre, Tyler Scheid
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              Updated:
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