Glossary

1	EMR	Electronic Medical Record
2	MRP	Most Responsible Physician
3	OMD	Ontario Medical Documentation

1. Encounter Notes

1.1 Summary

1.1.1 Business Need

Defined users:

MRP doctors, residents, nurses, team assistants and other medical staff with the credentials and rights to access OSCAR web-site. General user is given administrative rights.
Super User/Administrator with full rights:

Add/Edit/Delete
Reactivate account
Access to admin part of the OSCAR

Main purpose of Encounter Notes is:

To automatically include user identifiers
To be edited by different users
To enter notes by users with no rights to access patient data
To copy measurements from encounter notes into measurements section

1.1.2. Description

Encounter Notes use cases are designed to enable users with different rights to add and edit notes. User identifiers will be included automatically when note is added or edited. Encounter notes can be edited by more than one person and staff with no rights to patient data is able to enter notes. When measurements are entered in Encounter Note, it should be copied into Measurements section by the system with ability to be viewed.

NOTE:

Encounter Notes requirement “Include more than one diagnosis per encounter (can be via free text or coding)” is out of scope in the current document and requires more clarification.
Encounter Notes requirement “Measurements entered in encounter note should be copied into measurements” -> functionality is not working for now.

1.1.3. Pre-action requirements/state:

OSCAR McMaster Test Version 12.1, system, and DB are up, configured and working as expected.

1.1.4. Post-action state:

OSCAR McMaster Test Version 12.1 is running and behaving as expected.
OSCAR McMaster Test Version 12.1 has all functionality prior to the change (outside of removing functionality intentionally)

1.2 Flow of Events

This section describes the main flow of the Use Case and system responses.

User identifiers are included automatically

Num.	Step	Description	System Response	User
1	Connect to the OSCAR main page	Launch URL: http://192.168.1.202:8080/Oscar12_1/index.jsp	OSCAR main page with the login is opened	General User
2	Log In	Enter user's valid credentials (User Name / Password/2nd Level Pass code if applicable)	By entering right credentials user is getting system verification acceptance	General User
3	Search the patient name	Access Patient Search Results page from Search Tab	Patient search results page is accessible from Search Tab by name	General User
4	Activate eChart module	Select E hyperlink to open eChart from the current record	eChart module is opened for the selected patient	General User
5	Add a New Note	Enter note, sign and save it	Note is saved	General User
6	Verify User identifiers are included automatically	Open the note and verify that User identifiers (Editors) are included automatically in the note	User identifiers (Editors) are included automatically in the note	General User

1.2.1 Alternate Flows of Events

This section describes the alternative flow of events based on variations in the main Use Case scenario that still result in a Successful End Condition at completion of the Use Case.

Alternate Flow 1

Edit a note by several users

Num.	Step	Description	System Response	User
	Pre-condition	Notes are added
1	Connect to the OSCAR main page	Launch URL: http://192.168.1.202:8080/Oscar12_1/index.jsp	OSCAR main page with the login is opened	General User
2	Log In as a different user	Enter different user's valid credentials (User Name / Password/2nd Level Pass code if applicable)	By entering right credentials user is getting system verification acceptance	General User
3	Search patient by name	Access Patient Search Results page from Search Tab	Patient search results page is accessible from Search Tab by name	General User
4	Activate eChart module	Select E hyperlink to open eChart from the current record	eChart module is opened for the selected patient	General User
5	Edit a note	Edit existent note created by a different user, sign and save	Note is edited and saved	General User
6	Note is edited by more that one user	Verify that note is edited by more that one user	Note is edited by more than one user and User identifiers display editors names	General User

Alternate Flow 2

Add notes by not authorized to patient data users

Num.	Step	Description	System Response	User
	Pre-condition:	A user should have credentials with limited access to patient data (E.g. Receptionist)
1	Connect to the OSCAR main page	Launch URL: http://192.168.1.202:8080/Oscar12_1/index.jsp	OSCAR main page with the login is opened	General user
2	Log In	Enter user's valid credentials (User Name / Password/2nd Level Pass code if applicable)	By entering right credentials user is getting system verification acceptance	General user
	Change provider's role	Go to Admin-> Assign Role to Provider	Change provider's role to Receptionist and log out	General user
	Log In as a provider with Receptionist role	Enter user's valid credentials (User Name / Password/2nd Level Pass code if applicable)	By entering right credentials user is getting system verification acceptance	Receptionist
3	Search patient by name	Access Patient Search Results page from Search Tab	Patient search results page is accessible from Search Tab by name	Receptionist
4	Activate eChart module	Select E hyperlink to open eChart from the current record	eChart module is opened for the selected patient	Receptionist
5	Add a New Note	Enter note, sign and save it	Note is saved and added	Receptionist

Alternate Flow 3

Encounter Notes Measurements should be copied into measurements section

Num.	Step	Description	System Response	User
1	Connect to the OSCAR main page	Launch URL: http://192.168.1.202:8080/Oscar12_1/index.jsp	OSCAR main page with the login is opened	General User
2	Log In	Enter user's valid credentials (User Name / Password/2nd Level Pass code if applicable)	By entering right credentials user is getting system verification acceptance	General User
3	Search patient by name	Access Patient Search Results page from Search Tab	Patient search results page is accessible from Search Tab by name	General User
4	Activate eChart module	Select E hyperlink to open eChart from the current record	eChart module is opened for the selected patient	General User
5	Add a New Note with measurements	Enter a measurements (e.g. BP 120/90) in the note, sign and save	Note with measurements is saved and added	General User
6	Measurements from encounter notes are copied into measurements section	Verify measurements from encounter notes are copied into measurements section and available to view	Measurements from encounter notes are copied into measurements section and available to view	General User

1.2.2 Exception Flows of Events (Negative)

N/A

OSCAR EMR

Use Cases Encounter Notes