Home Forums Discussions Feedback and Recommendations Grace period for fixing mistakes and typos

I wish AC had a feature where mistakes in the chart could be changed. Of course we can (and do) use an addendum to note errors that aren't caught before the chart is signed. But it would be SO nice to have a grace period before the chart was written in stone.

Maybe we're more mistake prone than other practices, but it sure is frustrating to click too fast and then have to write up an addendum.

How long a grace period would you want?

I know only doctors opinions matter, but it's been indicated to me that 24 hrs would be good. Sometimes they just don't want to sign off the chart until they are sure they have everything. Then they have work at the end of the day... Which Should Never Happen.

And it would prevent charts from being lost on their way to the MA to document shots or likewise. (what is the AC way to do that? get out, find patient in list, send message? or forward chart? or, perhaps, point emphatically.)

Hi Ben, Why do you have to forward a chart to an MA to document shots?

This board might not be the best place for sarcastic remarks about doctors IMHO.

I guess what I was getting at is if you have some type of grace period or any length of time to change or modify things in a progress note, you will have to have a very good audit trail.

While it is easy to doctor (sorry for the pun) a paper progress note, it is evident and we were always taught to use one line only to scratch through it and then write the word error above it and initial or sign. If one had no audit trail and had even hours to change notes, there could be issues with doctoring notes.

I didn't mean it as a shot against doctors, but as a self conscious acknowledgment that my perspective is woefully short sighted. I'm not as sensitive to legal issues as doctors are, so I forgot how important it is that a doctor not be able to go back and document that they did send that kid to the ER for [some reason]. My heart sank when I read that, I love you guys.

Really sorry.

They don't Bert, it just seems to me that it should be possible to have the techs document what they have done without the doctor entering it into the note. In case a tech forgot to do something, though I can't see that ever happening with this office.

Sorry again.

I guess I have a hard time following the logistics. My MA triages the patient and forwards the chart to me. I see the patient, do the note and sign it. My MA gives the charts and documents it in AC in the summary section of the chart. It doesn't have to be in the same "chart" that I charted in. If I am understanding you.

And, we love you too Benjamin. I didn't take it that way -- it's just the danger of email or user board writing. That's what emoticons and lol and J/K are for, but even then.... things can be perceived differently.

Looks like you meant it the way you noted, it was misperceived, comment made, and you cleared up. Its done.

Right, well I said vaccines, but I was thinking more generally, for labs, radiology, them doing a strep test or ekg. In that case the doctor documents it then tells the MA what to do. I'll tell the doctors to keep the charts then send messages instead, but that will require them to type/template the instructions twice.

Is that any clearer?

Yes. Whenever this topics come up, I think it's hard for everyone to relate because we all do it differently, which makes total sense. If it works for you, then that's great.

yeah, i am becoming sensitive to the common "doctors are" generalizations and reacted perhaps too quickly. so "my bad." Nice to know you are cuddly

I also hate typos, but when I look at my hospital dictation I am amazed what a trained transcriptionist will interpret. I really can't find a way to fix all of those errors - at some point we have to admit we are human and let them go. Truthfully we as doctors are lousy at grammar and syntax on our notes - patients, lawyers, judges all know that.

Can there be a function in which correction of typos or few words may be done the way written charts are done? i.e. line through error followed by correction with date and time stamp.

Regarding the flow from MA to provider; we have just implemented computers in all the exam rooms and since we have multiple providers and multiple MA's it is easy for an MA to forward to the wrong provider. Or, sometimes the scheduled provider gets busy and another provider offers to see the patient.

So, we have all the intake folks input their data into AC and then log out using the 'windows' +L keys. Then when a provider logs in they are immediately at the note. Then they either complete the note during the encounter or forward it to themselves. So far, it's working pretty well. I have not yet found a downside.

Of course, the first day we implemented the exam room computers one of our nurses did not log out and when the provider entered the room, the patient was purusing someone elses MR. Yikes!

Wow! What did you do or tell that patient?

I think a Taser could be appropriately used in that circumstance.

I agree. Who would have the b...ls to do that? Complete grounds for dismissal.

I think I would have said. Do you want me to leave so you can read the rest of his chart?

Hello Barb
Could you just send them back to yourself and then close them the next day? I used to send it to the nurses for their documentation, but now I have them document it in a separate note. Has helped a lot and I get to review my note if necessary. Hang in there, it does get easier.

Again, unless you had a very top notch and accurate audit system, this could cause a lot of medicolegal implications. The easiest and still best way to do this is either via an addendum or even a message which is better for me.

Just pull up the message, write correction to progress note on 9/21/09, type the correction and save to the chart. It will then always be right next to the note.

With paper, it was obvious when you changed something as you struck through it with one line, wrote error and initialed it. What you would want to do may entail actually deleting the error and correcting it. It may be possible to correct the error by striking through and initialing, but even the big boys EMRs don't seem to have that feature as I have never seen it on progress notes sent to me.

IMO, and this is just my opinion, even signing them off the next day would raise some eyebrows if there were ever issues with that visit. The EMR should document when the note was finally finally done. It would seem easy to see a patient who then does not go to the ED that night when the fever suddenly spikes (just an example), and there is a bad outcome. I would be tempted (wouldn't do it) to go back and write (patient was informed to go to ED for fever spikes -- and change the 103 temp in the Vital Signs to 100.1. This is just a thought.

I have trouble with not being as aware of the medical-legal stuff. It just gripes me that there's no way to fix simple errors without addenduming the chart to death.

We are getting better - but the first few days with the tablets there were some absolutely bizarre notes that were entered. Now everyone is better at checking over the boxes before they hit enter.

Coming from a non-medical perspective the whole thing just seems like there ought to be a way to fix mistakes while still ensuring that charts accurately reflect what happened during the visit.

By the way -- I was leafing through an old FMP magazine and the article at the back was about how charting has changed over the years. We've (you've) gone from a patient note consisting of "pharyngitis -> penicillin" to what we have now, in large part because charts aren't just for doctors. Everyone who has a stake in modern medicine also has a stake in the charting.

I know I'm complaining about something that probably can't get fixed. But I wish it could!

And it helps to hear how other offices manage their flow! So thank you all for that!

I wish I was able to finish every note everyday, but for me, it's just not possible. Many of my patients are on a lot of meds and have multiple problems-over half the visits at a 99214 level. With doing "modified open access", I often get slammed at the end of the day.

While most notes are closed on the day the patient is seen, sometimes it's just not physically possible. Adding stuff like details to an exam, critical parts of the history that didn't get in on the first pass, are too hard to ever recover in AC if they are relegated to an addendum. That's one of the weaknesses of the program.

I allow myself some time each morning before jumping back into the fray. I use that time to review the patients I will be seeing and anything that might still be pending from the day before.

Barb, you'll eventually find a system that works for you.

PS Wouldn't it be nice if we didn't have to practice defensive medicine. I went to medical school with a gal from Austria. When we got to the floors, she asked a profound question, "Why do we waste so much time writing things down instead of caring for the patients?"

Well, I guess with pediatrics, there is just much less to document. And, I am not the great documenter anyway. I try to make it a policy to always finish the note in the room (in fact always) and even do letters, etc. And, before that sounds egotistical, this is at the expense of great notes and letters. I recall in the past, I think before AC, I used to do two or three letters a day on perfect gray paper which was a 24 thickness. My letters are horrible compared.

On another note, pardon the pun, I was just playing around with an idea that doesn't quite solve everyone's issues, but I still think it's better, because being able to change a note after the fact just isn't safe. One of the reasons it was scary having access to Version 3's database was the temptation to be able to change any note at anytime. And, I don't mean medicolegal as in a litiginous environment, I mean by we, the doctors. I haven't been sued yet, but I have had records subpoenad which I knew weren't being asked for to add to the family scrapbook. Boy, I would have loved to go back and add to a note and document like crazy. And, again, I know two weeks or two months is different than two hours but where do you draw the line? Three hours later? When you just notice that the three week old you saw had a temp of 101.5, and you diagnosed it with a cold and didn't see the temp? If you couldn't get hold of them family, it would sure be tempting to change that to 99.5.

So, if you had to change a note even months later, you could do the following. I know that many of us use Shortkeys, one of the greatest little programs ever. I just made a shortkey for Error corrected by Bert Adams, MD. 9/21/0919:48 using "ee e" (space there so it doesn't add it again. I simply wrote the correct words in the chart and put that underneath. I made a shortkey for This note edited for errors on 9/21/09 by using "cc c" that I put in the chief complaint so it would show up in the past visit section.

Oh, and I forgot to mention, I simply pulled up the same note already saved and added the corrections directly to it. You can either keep what is there and add the addendum directly to the chart with the sig and date/time stamp or actually correct the words themselves. This way you still have the original as an audit.

Again, this isn't the exact wish in the thread, but I thought it may help.

And, Vicki I do understand your having a lot more difficult patients and charts.

I also hate not being able to do some limited correction, but I agree that I have never seen any EMR that lets you do this - I also think it would be good if AC would put on the bottom of the page when the note was finalized. I think that would make us all a lot more accountable for finishing our notes in a timely fashion. I know that my hospital cannot bill for any of my admits until I sign everything, dictate all notes and discharge summaries and finalize everything. This motivates them to eventually get on the case of a doctor who is perpetually late(not me - I like to bill also and do not do any billing until this step).

I also do a fair amount of 99214's and work hard on finishing them that day (sometimes I am at the office on call until 11:00 pm) - so if you can cut out sleep and going home you would be better off......

P.S. Vicki is creeping back up the top 10 board.

Bert, when you " simply pulled up the same note already saved and added the corrections directly to it. You can either keep what is there and add the addendum directly to the chart with the sig and date/time stamp or actually correct the words themselves. This way you still have the original as an audit."

Are you saying you then have two copies of the note, the original, and the corrected one (perhaps under a different date)?

And you do this rather than just doing an addendum?

I guess this has the advantage of being able to print out the corrected note only when sending to a consultant, etc. Is that why you choose to do it this way?

Just wondering,

Sky

Actually, I don't do it that way. Part of the reason I stay late at night is I enjoy trying to come up with workarounds. I always look at fixes or ways of doing things in the EMR as how one would do it in a paper chart, given we have many more years of experience with that.

So, given that, if one writes a progress note and says 30 mg of Zantac and meant 60 mg, they would strike through the 30 mg, write 60 mg above it, write the word "error" and then initial it. They wouldn't write an addendum at the bottom of the note stating I meant to say 60 mg. Now, it isn't the perfect analogy but pretty close.

I think (given what we have with AC and most EMRs), the closest to an audit trail when correcting would be to open the chart again with the original version, make a change which is adjacent to the error and time and date stamp it digitally with Shortkeys.

I SHOULD POINT OUT that this isn't the answer to the original question that Barb asked. Just a thought on how to correct a wrong note.

This sounds like an ideal solution! You're right, it's not the answer to my original question (rant) but it would work very well. The date stamp presents a clear audit trail, which covers the medicolegal angle.

We've gotten much better with the tablet input and checking to make sure the handwriting has been correctly transcribed. btw, a medical dictionary really helped with this!

Not sure if gave the link. Many on here use it. It's a great little program. I think there are others similar, but this one seems to be the most straightforward. And, you can network it so can be used by all the PCs.

Since we always have one section for review of systems, we have one called ma1 and ma2, which states: Patient was put in room by Brianna at such and such a time.

http://www.shortkeys.com/

Hello,
At a risk management workshop I was trained to never write the word "error" in a chart. Line through with initials and date should be enough.

Writing the word sets you up for more liability.

Attorney:
"Well doctor, I see that you have made several errors here.
Do you make a lot of errors. Hmm, here in this one note I see
that you made x number of mistakes. You sure make a lot of mistakes don't you?

Since Steven has been nice enough to get 4 posts ahead of me, I thought I'd add this little tidbit

If I had a vote that counted, I would vote for the addendum to show up at the bottom of the note.

Attorney:

"Well doctor, I see you have a lot of addendums here. Do
you always forget that much or make that many errors that
need that many addendums?

I agree with Vicki addendums are addended to something and should automatically pull up when attached to a note.