This post is the policy for using comments in Medinfo software. A subsequent post will show the process of entering comments.
There are several different types of comments in HIIG:
- Donor Global
- Patient Global
- Analytical Comments
- Result Comments
- Contraindication Comments
Global Comments appear on the first main screen of either the donor or patient record. The presence of comments is indicated by a bar at the bottom of the screen (in yellow or blue saying Presence of Comments. Double-clicking opens the list of entered comments.
Examination/Results Comments appear only when you open the result to which it is attached. You must know in advance to which result they are linked to find them.
Contraindication Comments appear when entering a donor deferral code
At HMC, we will enter examination/results comments again as global comments (donor or patient) so it is easy for staff to retrieve them and see them with all other comments. You can do this by cut and paste.
Physicians may enter any of these comment types. Comments may be entered before or after a test is authorized/verified. If entered after authorization, the test must be modified to accept the comment and require a special password (not the user sign-into HIIG). Only results/examination comments are visible in the patient’s medical record. Global, analysis, and contraindication comments are visible only in HIIG! Donor comments are only visible in HIIG.
The presence of comments documents physician review of abnormal results as required by the various accreditation standards.
- Only designated staff may enter comments.
- Comments entered after authorization/verification of results will modify the donor/patient record and require a special, high-level password distinctly different from the normal user password.
- Enter comments in the following situations:
- Telephone call documentation (e.g. critical values).
- Interpretations of donor or patient test results, transfusion reactions, etc.
- Instructions for the selection of specific and/or modified blood components
- Donor eligibility issues (e.g. donor marker testing abnormalities and disposition)
- Donor reactions
- Donor counseling documentation (e.g. donor counseled at 0930 on 24/3/14 about his abnormal result).
- Any special instructions to staff
- Any other situation where the transfusion physician/supervisor or designate determines it is desirable to enter a comment
- Copy all results/examination-comments and also enter then as global comments against the patient or donor record as applicable.
- Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA
- Workflows 1001-1005, Medinfo Hematos IIG, 2013-2014.