Vicki I have lost a few notes myself. Very upsetting. Most all of mine were when I was forwarding a note to the MA for them to add things to the note before I sign it. Of course no one who has made a mistake, knows that they did, so they all deny responsibility for the lost note, (the same as I do when I lose a note all by myself).
There are two tips:
1- the "deleted notes" will allow you to recover the note IF you figure out it is lost, before the day is over. Most of us have had this frustration, you are behind because you are not running at full speed yet. When you get the hang of it, you will also realize right away when a note is lost, because your inbox will no longer have 300+ messages! (OK, some days it will, but not most!)
2- If you use a scrap of paper, (we do, it is used to record the vitals, and carry any information regarding co-pays to the biller) The scrap of paper will have a little real data on it. Ours has the vitals and a few words of the chief complaint. Now if you go to the chart where the note was lost, some data is still there! If an Rx was written it will remain in the RX box even if the note was not signed! Likewise the Dx will remain in the summary and in the drop down list IF you coded the chart during the visit.
At one time I had several of these, so I just made a template:" This is a reconstruction of the office note on this date" "The original note was lost during the early days of our implementation of an EMR and all of the data here was re-entered from factual written documentation that we had." Then I reentered the vitals, the DX if I could, the Rx if there was one and NO PHYSICAL EXAM since I could not provide any reasonable assurance that I was not just making it up. IMHO this is the best you can do, and you should just move on. It is lost and there is nothing else you can reasonably do.
My associate still sends her charts to the staff, and they send the notes back and it all works smoothly. I do not choose to do it this way. (Just chicken I guess!)
Hope this helps.
