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.
ISIS and CGI Restricted
Doc. #PM037-UB-Manage Clinical Notes
Version 01.01
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Issue Date: August 03, 2004
Zoological Information Management System (ZIMS)
Manage Clinical Notes
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
ISIS and CGI Restricted
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Zoological Information Management System (ZIMS)
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Table of Contents
1.0
1.1
1.2
1.3
1.4
1.5
2.0
2.1
2.2
2.3
3.0
OVERVIEW ..................................................................................................................................... 1
USE CASE ID UC2019 ..................................................................................................................... 1
USE CASE NAME MANAGE CLINICAL NOTES .................................................................................. 1
USE CASE DESCRIPTION .................................................................................................................. 1
USE CASE PRIORITY ........................................................................................................................ 1
FREQUENCY OF USE ........................................................................................................................ 1
ACTORS ........................................................................................................................................... 2
PRIMARY ACTORS ........................................................................................................................... 2
SECONDARY ACTORS ...................................................................................................................... 2
STAKEHOLDERS ............................................................................................................................... 2
CONDITIONS .................................................................................................................................. 3
3.1
TRIGGERS ........................................................................................................................................ 3
3.2
PRE-CONDITIONS ............................................................................................................................ 3
3.3
CONSTRAINTS.................................................................................................................................. 3
3.4
POST-CONDITIONS .......................................................................................................................... 3
3.4.1
Success Post-Conditions ......................................................................................................... 3
3.4.2
Failed Post Conditions ........................................................................................................... 3
4.0
FLOW OF EVENTS ........................................................................................................................ 4
4.1
BASIC FLOW .................................................................................................................................... 4
4.2
ALTERNATIVE FLOWS ..................................................................................................................... 4
4.2.1
Alternative Flow- Approve Clinical Notes .............................................................................. 4
4.3
INCLUDED USE CASES ..................................................................................................................... 4
5.0
INFORMATION REQUIRED ........................................................................................................ 5
6.0
BUSINESS RULES .......................................................................................................................... 6
7.0
OTHER REQUIREMENTS, ISSUES AND CONSIDERATIONS.............................................. 7
7.1
7.2
7.3
7.4
7.5
8.0
SPECIAL REQUIREMENTS ................................................................................................................. 7
ASSUMPTIONS ................................................................................................................................. 7
ISSUES ............................................................................................................................................. 7
CONSIDERATIONS ............................................................................................................................ 7
CROSS REFERENCES ........................................................................................................................ 7
WORKFLOWS................................................................................................................................. 8
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Zoological Information Management System (ZIMS)
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1.0 Overview
1.1
Use Case ID
BUC2019
1.2
Use Case Name
Manage Clinical Notes
1.3
Use 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.
1.4
Use Case Priority
High
1.5
Frequency of Use
Daily
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2.0 Actors
2.1
Primary Actors
Veterinarian
2.2

Creates Clinical Notes
Secondary Actors
Technician

Views Clinical Notes
Health Keeper

Views Clinical Notes
Health care
Staff

Views Clinical Notes
Veterinarian
Staff

Views Clinical Notes
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
2.3
Stakeholders
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3.0 Conditions
3.1
Triggers
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.
3.2
Pre-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.
3.3 Constraints
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.
3.4
Post-Conditions
3.4.1 Success 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
3.4.2 Failed 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
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4.0 Flow of Events
4.1 Basic 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.
3. Veterinarian uses a pre-formatted template to perform data-entry, for each type of
activity.
4. Veterinarian completes initial recording of the clinical notes and save them as
‘unapproved’ clinical notes.
5. Veterinarian reviews clinical notes if needed amends it and saves the revised
version, the revised version is saved as ‘approved’ version.
6. Veterinarian links the clinical note to pre-existing medical activity.
7. If notes have to be approved then go to Alternative Flow 4.2.1.
8. Process ends
4.2
Alternative Flows
4.2.1 Alternative 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
4.3
Included Use Cases
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5.0 Information Required
1.
2.
3.
4.
5.
6.
7.
8.
9.
Medical activity (Examination, Treatment, Sample test result, Medical procedure)
Animal identity
Animal observations
Species details
Associated picture / video specific to the clinical notes
Results of test samples
Template from protocol or standard template to input the clinical Notes
Saving a formatted note as a template.
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.
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6.0 Business 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
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7.0 Other Requirements, Issues and Considerations
7.1
Special 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
7.2
Assumptions
None
7.3 Issues
1. How will these notes stored i.e. based on an animal ID or based on a particular
case?
7.4
Considerations
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.
7.5
Cross References
WF2007
Organ system evaluation (Examination and Assessment)
WF2013
Sample analysis
WF2014
Necropsy
WF2019
Multimedia storage – diagnostic Imaging
WF2020
Surgery
WF2023
Immobilization
WF2027
Parasite control program
UC0010
Record animal observation
UC0011
Review / revise animal observation
UC0012
Record animal management action
UC0013
Review / revise animal management action
UC2004
Duplicate UC0010
UC2017
Record / revise diagnostics
UC2019
Record / revise / search clinical notes
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8.0 Workflows
None
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