Sometimes a clinical document needs to be amended. In SmartCare, there is a way to edit a document, which creates a second version of the document. The old version remains in the system, and is available for view, which helps for auditing purposes.
You can only amend documents that you are the author of. If you are a proxy for another person, you will not be able to amend their documents.
If a document is allowed to be editable by non-authors, then anyone can amend that type of document. Only a few documents in SmartCare have this allowance. These are non-clinical documents, meaning no clinical decision making is included in the document itself. For example, the PSC-35 is a document that the parent of a youth client completes. The author is simply entering this information into SmartCare as a data-entry function. This document is therefore editable by non-authors, as no clinical decisions are made here. The CANS is a document that a CANS-certified clinical person must complete. This document requires a person with clinical experience to complete, and the scores are entered based on the author’s clinical judgment. This document is therefore not editable by non-authors, as it includes clinical decision-making.
To amend a signed clinical document, follow the steps below.
- Navigate to the document you want to amend.
- In the document ribbon, click on the Edit icon.
- A Confirmation Message will pop up, indicating that a new version of this document is about to be created. Click OK to continue.
- This will “unlock” the document by creating a new version and pulling all the information from the previous version forward. Make any changes you need to.
- Click Sign when you’re finished. You may now close the document.
How to View an Old Version of a Signed Document
For audit purposes, sometimes it’s necessary to view an older version of a document. Comparing the current version to the previous version will also show you what changes were made during the amendment process.
- Navigate to the document you want to view.
- Click on the Plus icon to expand the document ribbon.
- This will show you all versions of the document. The newest version will always be selected by default, and will always be at the top of the Other Versions list. To view an older version, select the radio button next to the version you want to view.
- You can also see who signed what versions by looking at the Signed By section. The number in the parentheses will indicate which version the signature is associated with.
- This will load the older version into the PDF viewer. When you close this document and then re-open it, the system will still default the view to the newest version.
