/ Zoological Information Management System (ZIMS) Project
Manage Clinical Notes
/ Client: / International Species Information System (ISIS)
Prepared by:
CGI INFORMATION SYSTEMS AND MANAGEMENT CONSULTANTS INC.
Author / Savio Pereira
Issue Date / August 03, 2004
Version / 01.01
Document Reference / PM037-UB-Manage Clinical Notes v01.00
Template Version / PMF001 – v01.00
Proprietary Information Notice: This document has been developed and created by ZIMS project team. The information contained herein is confidential and proprietary and cannot be used unless specifically permitted in writing by CGI and International Species Information System (ISIS) in connection with the Zoological Information Management System Project. The recipient of this document, by its retention and use, agrees to hold this document and its content in strict confidence and to protect the same from loss, theft or unauthorized use. This document shall not be copied or communicated to any third party, in whole or in part by any means without the prior written consent of ZIMS PMO. This Proprietary Information Notice is an integral part of this document and shall not be removed or altered.
Zoological Information Management System (ZIMS)
Manage Clinical Notes /

Document Location

Current released documentation for this project can be found on the ZIMS website. Printed documents and locally copied files may become obsolete due to changes to the master document. Please contact the Project Control Officer of the ZIMS project to obtain a printed copy of the latest version of the document.

Approvals

This document requires the following approvals.

Name / Organization
Mark Switzer / CGI
Victor Risinger / CGI
Syed Hassan / ISIS

Signed approval forms are filed in the Project Control Book (PCB).

Distribution List – Controlled

The people on the controlled list will be notified of updates to this document. Others should ensure that they are working from a current copy of this document before making decisions based on the information contained within the document. This document has been distributed to:

Name / Organization
Diane Akai / CGI
Mudassar Habib / Inforica
Rohan D’souza / Inforica
Savio Pereira / Inforica
Mark Switzer / CGI
Victor Risinger / CGI
Inna Pylypchuck / CGI
Tariq Feroz / Inforica

Distribution List – Uncontrolled

This document is available to all CGI and authorized ISIS personnel on the ZIMS website. All users of the ZIMS project are advised to visit the website for the current version of the document.

Document Version History

Version Number / Revision Date / Summary of Changes / Modified by
00.01 / July 9th, 2004 / Creation of the Use Case 2019 / Savio Pereira
00.02 / July 14th, 2004 / Reviewed / Mudasser Habib
00.03 / July 23, 2004 / Added the information captured during the JAD1 / Savio Pereira
00.04 / July 27, 2004 / Updated the Use Case based on Mudassar’s feedback / Savio Pereira
00.05 / August 03, 2004 / Reviewed / Mudasser Habib
00.06 / August 03, 2004 / Reviewed / Tariq Feroz
01.00 / August 3, 2004 / Released to ISIS / Mark Switzer

Table of Contents

1.0Overview

1.1Use Case ID UC2019

1.2Use Case Name Manage Clinical Notes

1.3Use Case Description

1.4Use Case Priority

1.5Frequency of Use

2.0Actors

2.1Primary Actors

2.2Secondary Actors

2.3Stakeholders

3.0Conditions

3.1Triggers

3.2Pre-Conditions

3.3Constraints

3.4Post-Conditions

3.4.1Success Post-Conditions

3.4.2Failed Post Conditions

4.0Flow of Events

4.1Basic Flow

4.2Alternative Flows

4.2.1Alternative Flow- Approve Clinical Notes

4.3Included Use Cases

5.0Information Required

6.0Business Rules

7.0Other Requirements, Issues and Considerations

7.1Special Requirements

7.2Assumptions

7.3Issues

7.4Considerations

7.5Cross References

8.0Workflows

ISIS and CGI Restricted
Doc. #PM037-UB-Manage Clinical Notes / Page 1 / Version 01.01
Issue Date: August 03, 2004
Zoological Information Management System (ZIMS)
Manage Clinical Notes /

1.0Overview

1.1Use Case ID

BUC2019

1.2Use Case NameManage Clinical Notes

1.3Use Case Description

Provide the facility to create / edit a free form structured text based notes associated with various medical activities such as procedures, observations, treatment for animals, species and enclosures. The user should be able to search these notes based on key words, character strings etc.

1.4Use Case Priority

High

1.5Frequency of Use

Daily

2.0Actors

2.1Primary Actors

Veterinarian /
  • Creates Clinical Notes

2.2Secondary Actors

Technician /
  • Views Clinical Notes

Health Keeper /
  • Views Clinical Notes

Health care Staff /
  • Views Clinical Notes

Veterinarian Staff /
  • Views Clinical Notes

2.3Stakeholders

General Management /
  • Views / reviews Clinical Notes

Receiving Institution /
  • Views / reviews Clinical Notes

Management Staff /
  • Views / reviews Clinical Notes

Homeland Security /
  • Views Clinical Notes

USDA /
  • Views Clinical Notes

Animal welfare /
  • Views Clinical Notes

3.0Conditions

3.1Triggers

  1. Record of Animal accession must be established.
  2. Vet examines an animal and records observations and diagnosis.
  3. A medical test is completed and Vet records diagnostics about the result or problem
  4. Vet performs a medical procedure.

3.2Pre-Conditions

  1. Animal must be identified before clinical notes can be produced
  2. Medical activity has been performed and activity record has been created in the system.

3.3Constraints

  1. Unable to identify the animal so the clinical notes are attached to the enclosure or species and the animal ID is resolved later.
  2. Spelling errors can occur which limit the ability to search data on specific problem or medical condition or treatment
  3. Sometimes, wrong accession number is given by the observer, which results in corrective action. To correct the error data is transferred from one animal / enclosure / species to another animal / enclosure / species.

3.4Post-Conditions

3.4.1Success Post-Conditions

Free format text containing Clinical Notes have been added to a medical case of an animal or a group of animals and saved

3.4.2Failed Post Conditions

Free format text containing Clinical notes have not been added to a medical case of an animal or a group of animals nor saved

4.0Flow of Events

4.1Basic Flow

  1. Veterinarian receives a call / message from the keeper / aquarist regarding a problem to an animal / species that may require medical evaluation and/or procedure
  2. Once the Veterinarian has performed the medical evaluation a clinical note is associated with this medical activity. The information captured may be structured as follows:
  1. Subjective Data: Presents the problem from the patients point of view, or from a lay-person observers point of view.
  2. Objective Data: This section captures the veterinarian’s observations during the medical evaluation / procedure and captures the objective findings gathered by observation, physical exam, lab results etc..
  3. Assessment: This section identifies the working diagnosis of the problem
  4. Plan - this section outlines the plan the Veterinarian will carry out.
  1. Veterinarian uses a pre-formatted template to perform data-entry, for each type of activity.
  2. Veterinarian completes initial recording of the clinical notes and save them as ‘unapproved’ clinical notes.
  3. Veterinarian reviews clinical notes if needed amends it and saves the revised version, the revised version is saved as ‘approved’ version.
  4. Veterinarian links the clinical note to pre-existing medical activity.
  5. If notes have to be approved then go to Alternative Flow 4.2.1.
  6. Process ends

4.2Alternative Flows

4.2.1Alternative Flow- Approve Clinical Notes

  1. Review Clinical Notes that have been entered (Technician enters the notes into the system and the Vet approves them).
  2. Approve Clinical Notes. P.S. Clinical notes that have not been approved / authorized will not be part of any case / problem nor attached to any particular animal or species.
  3. Return to the Basic Flow step 8

4.3Included Use Cases

5.0Information Required

  1. Medical activity (Examination, Treatment, Sample test result, Medical procedure)
  2. Animal identity
  3. Animal observations
  4. Species details
  5. Associated picture / video specific to the clinical notes
  6. Results of test samples
  7. Template from protocol or standard template to input the clinical Notes
  8. Saving a formatted note as a template.
  9. Recording of Date and Time of the data entry and the person inputting the information and / or approving it.
  10. Recording of Date and Time of the occurrence of the incident
  11. Audit trail of the clinical notes changed after approval.

6.0Business Rules

  1. Clinical notes cannot be deleted.
  2. Broad legal and regulatory rules apply to the reporting of diseases.
  3. Sharing of Clinical notes based on user profile
  4. Clinical notes should not be shared with non-vet staff

7.0Other Requirements, Issues and Considerations

7.1Special Requirements

  1. Local language conversion of the system including translating the screen labels but not including the free text entered.
  2. Text search on key words
  3. Spell check
  4. Rich text formatting, hyperlink option
  5. Acceptable presentation and publishing
  6. Linkage to multimedia files

7.2Assumptions

None

7.3Issues

  1. How will these notes stored i.e. based on an animal ID or based on a particular case?

7.4Considerations

Corrections can be made even months after the initial notes were created, sometimes the error is detected at annual inventory almost a year after the activity.

7.5Cross References

WF2007 Organ system evaluation (Examination and Assessment)

WF2013 Sample analysis

WF2014Necropsy

WF2019 Multimedia storage – diagnostic Imaging

WF2020 Surgery

WF2023 Immobilization

WF2027 Parasite control program

UC0010Record animal observation

UC0011Review / revise animal observation

UC0012Record animal management action

UC0013Review / revise animal management action

UC2004Duplicate UC0010

UC2017Record / revise diagnostics

UC2019Record / revise / search clinical notes

8.0Workflows

None

ISIS and CGI Restricted
Doc. #: PM037-UB-Manage Clinical Notes / Page 1 / Version 01.01
Issue Date: August 03, 2004