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Audit information

of

Audit information

from

Contsys/ISO 13940:2015

Source

Audit information (contsys): documentation of the details of a revision of a base component

for

Audit information

from

Minimum Operational Data Set

Source

Information about when a record was created, modified, completed and authorised and by whom. NameDescriptionData Type - Datetime: -- Date an event occurred on the record. -- xs:dateTime - Audit type: -- Type of audit activity logged to the record. -- changeType -- Enumerations: --- creation: addition of new record --- amendment: if the change is logically a correction (e.g. of wrongly entered data) --- modification: if the change is logically a change, addition etc to the content --- attestation: attestation of item. An attestation is an explicit signing by one healthcare agent of particular content for various particular purposes, including: for authorisation of a controlled substance or procedure (e.g. sectioning of patient under mental health act); witnessing of content by senior clinical professional; indicating acknowledgement of content by intended recipient, e.g. GP who ordered a test result. --- deleted: deletion of existing item --- access: if the the record has been accessed - Description: -- Description of the change. -- xs:string - System Identifier: -- Identifier of the system where the information is committed. -- xs:string. - Reason: -- Reason for attestation. Attestations may be used in different ways as follows: --- Signing content at committal: for some reason, the information being committed needs to be digitally signed. --- Marking content for review and signing: data entered, completed and committed by a data-entry person e.g. a secretary, transcriptionist or student need to be reviewed and signed by a senior care worker. --- Post-committal signing: data committed with an Attestation in the is_pending state is reviewed and signed at a later point in tme by an appropriate member of staff. -- xs:string - Proof: -- Digital signature accompanying attestation. -- xs:string. - Committer: -- Care actor who committed the change to the record if applicable e.g. care worker who filled in a form. -- Care actor. - Record Identifier: -- Unique identifier for the record. -- xs:string.

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