Difference between revisions of "EHR Document Corrections"

Revision as of 23:02, 1 June 2012

Introduction

CURRENTLY IN PROGRESS BY JULIE BYARS BMI 512 SPRING 2012. PLEASE DO NOT ALTER what the text should say

The electronic health record (EHR) is the legal and business record of the healthcare organization1. Information in the EHR is relied upon to accurately and safely treat patients, as well as to carry out business including obtaining medical history for providers, billing purposes, and organizational reporting needs. Therefore, maintaining accurate information in the EHR is important. With a variety of staff members accessing the health record, errors can be expected to occur. When they do occur, it is important for an organization to have clearly defined policies and procedures for addressing these errors. In addition, it is the patient’s right to request amendment of information they find to be inaccurate. See HIPAA standard 45 CFR 164.526 for more information on this right2.

Altering electronic documents degrades the integrity of the record and careful consideration should be taken to ensure the necessity of corrections and adherence to the policies and procedures. Correction processes should be as transparent as possible and clearly identify altered records as such. This transparency is necessary when called upon to speak to the integrity of the documentation for audit and litigation purposes.

Guidelines

Developing Policies and Procedures

Each healthcare organization is responsible for determining their own policies and procedures for document corrections, amendments, and deletions. These policies and procedures should be in line with the American Health Information Management Association (AHIMA) guidelines1, HIPAA standards, and good judgment on the part of the Health Information Management administrator. Policies and procedures will vary depending on the organization and the EHR capabilities for managing alterations.

HIM Involvement

Corrections and deletions of finalized documentation may be best handled by the HIM department. This will ensure that the chart can be reviewed by a second party to confirm that the change is justified and the recommended course of action if different from the request of the user. This is in line with HIPAA standard for integrity 45 CFR 164.312(c)(1) which protects health information from improper alteration or destruction.

Specially trained and designated health information management (HIM) staff who are dedicated to upholding the integrity of the legal health and business record and well versed in the legal implications of the alterations should be responsible for assisting staff with document corrections. Alterations made to documents by HIM staff must be identifiable in audit logs for as long as the health records are maintained.

Types of Corrections

Addendums

Addendums add omitted information to an existing document without altering the original document. Example: Foot pain was not mentioned in original document. Addendum to original document notes that patient complained of pain in their left foot, rating pain as 3 out of 10 and a contusion was noted. No history of foot pain and patient indicated contusion followed dropping a box on the foot while moving. No treatment was provided at this time.

Amendments

Amendments are used to clarify information presented in the original document without altering the original document. Example: Amended documentation clarifies that the reference to “foot” means patient’s left foot.

Corrections

Corrections change the information in the document.

Example: Patient complained of pain in the right foot was noted in original document. Corrected information clarifies that pain was in the left foot.

Deletions

Deletions eliminate incorrect information from a closed/finalized document.

Example: A note was placed in the wrong patient’s chart so it is eliminated from the incorrect chart and recreated in the correct patient chart.

Request Process

Staff Requests

User requests for HIM involvement for alterations to the record should be in writing though email or an online request form. Information necessary for alteration includes a minimum of a unique patient identifier, clear identification of the document that needs alteration, the specific reason alteration is needed, the requested type of alteration, and permission from the user to alter the document. This information along with verification of the necessity and validity of the alteration by HIM staff will help protect the user, the HIM staff, and the organization in the event of audit or litigation. Records of these requests should be kept for the same duration that the health records are maintained.

Patient Requests

Patient requests to amend their protected health information it is recommended that these requests be in writing. HIPAA standard 45 CFR 164.526: Amendment of protected health information covers rules for addressing patient requests to amend PHI.

Correction Process

Addendums and amendments can generally be handled by the provider by adding a subdocument to the original document. All staff with EHR access should be trained of the appropriate uses for each of these subdocuments. A system should be in place to “soft delete” documents. This means that a document will be removed from view in the patient chart but will be available if needed for future audits and litigation. This is also in line with HIPAA standard for integrity 45 CFR 164.312(c)(1). Deletion of documents is a valid option when documents are entered into the wrong patient chart or the information contained in the document cannot be adequately addressed with an addendum or amendment subdocument or other means of correction and could affect future treatment or vital patient information. Corrections to Released Information Additional policies are needed to address how corrections to previously released information will be handled. These procedures should include a system or tool to track or identify addended, amended, and altered documents.

1. American Health Information Management Association. Amendment, Corrections and Deletions Technical Paper [Online]. 2011 Oct [cited 2012 June 1]; http://library.ahima.org/xpedio/groups/secure/documents/ahima/bok1_049534.hcsp?dDocName=bok1_049534

2. Health Insurance Portability and Accountability Act (HIPAA). http://www.gpo.gov/fdsys/search/pagedetails.action?granuleId=CRPT-104hrpt736&packageId=CRPT-104hrpt736