Adult Social Care Glossary, v 0.6

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

Information about when a record was created, modified, completed and authorised and by whom.

Name Description Data 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.