With their knowledge of the technology on the hospital network, IT staffers can help HIM managers set up policies and procedures for editing patient records, a key issue as more electronic data is used to improve quality of care and cost efficiencies.
While policymakers consider how to create EHR addendum policies, consider these best practices from Lou Ann Wiedemann, director of professional practice resources for the American Health Information Managers Association.
Common types of medical records edits:
- Addendum: Adding new documentation to an original entry with an explanation of why it's being added. Can be several sentences of new or clarifying data that must be tacked on to the original record of an episode of care so that future caregivers can see the complete story. Examples might include a discharge summary, lab results, a consultant's new reading of a radiology image, or patient progress notes;
- Amendment: Clarifying information added to an original note, typically one or two words such as misidentified drug allergy. Some hospitals let practitioners amend without tracking up to the point where they sign off on a record, at which time it's locked and uneditable without creating a newly signed addendum;
- Correction: Errors typically in demographic data such as wrong patient address or account number, discovered after final clinician sign-off. The nature of the erroneous data point can determine whether or not a clinician is required to re-sign the chart (often it isn't); Wiedemann said usually one person in the HIM staff has administrative authority to make changes like these (defined and agreed upon in hospital policy) in locked records;
- Deletion: Outright removal of information from a medical record; this should never be done, Wiedemann said; and
- Retraction: A clinical data entry error, such as entering data in the wrong patient's record. This information can be hidden or at the very least prohibited from being printed so that errant information isn't redistributed. In some cases, hospitals need to forward such retractions to other providers involved with a patient's care, such as when a hospital corrects an error for a discharged patient, so develop a policy surrounding EHR retractions that ensures the right providers are notified.
Best practices for managing electronic data:
- Know your EHR. Vendors have different terminology for different ways of locking down data. For example, "lock" and "seal" can mean different things -- to some vendors, "lock" means data can be viewed but not edited, and "sealed" means a record can only be viewed by users with appropriate administrative privileges. Apply security features so that clinicians cannot make edits after they've electronically signed/dated/timed a chart without going through a standard process that involves the records department, which will require a new signature accompanied with a date and time (a key compliance rule for some state laws as well as CMS's Conditions of Participation);
- Lock down administrative access to medical records so HIM managers can only make EHR addendums according to policy, and clinical staff cannot;
- Understand how audit logs work in your EHR, and make sure your auditing process is HIPAA compliant;
- Keep abreast of how vendor software updates will affect the editing process, i.e. a vendor might remove a buggy feature such as colored text, which in turn removes your ability to use colored text to represent updated patient data in a medical record;
- Think about how your edits will look on screen and printed on paper; i.e. all caps might seem fine in a paper records workflow, but might be difficult to read in an electronic medical workflow; and
- Make sure clinicians use their full first and last name for electronic signatures; you might know initials and recognize signatures on a paper chart, but in EHR systems, a full name is crucial -- especially in larger hospitals.
Let us know what you think about the story; email Don Fluckinger, Features Writer.