Home Forums Discussions Problems Changing the Date for an Encounter

A lot of times I am so busy seeing patients, that I decide to write my notes after I am done seeing everyone. It's inefficient, but I do it just to keep the line moving.

Sometimes I type my encounter notes the next day or so, but I forget to change the date. Once you sign it, you can't go back. This can cause problems when we try to match up when a patient was last seen.

Is anyone aware of a way to change the date on a past encounter? I understand the medical-legal aspects of altering a note once it is signed, but I think we should be able to update the date on a note to get it right.

At the very least, we should be able to go back and add an addendum such as 'late note entry for an encounter that took place on xx/xx/xxxx at xx:xx PM?'

Eternal issue which can never be solved, I believe. Many previous posts on this. Options were to "hold" charts for a designated time after signing off, for error correction. Not possible, I understand. Second option is to preserve the date and time stamp from the schedule when a chart is opened. None, I believe, will ever happen.

So what do I do? Add addendum on the date the patient was seen. "Recording error" "Patient was seen on ... and not .... as erroneously recorded." Save. Enter bill for the date actually seen. Delete billing information from the wrong encounter date. Curse and go on with life. Good luck. : )

I have used an addendum for this - just enter the correct information for this and point to the note in the chart. One suggestion is that in regards to doing the note later - try to at least open the chart at time of service - put vitals or something in it and then forward it to yourself. This puts the correct date and time in the note and the e-mail will force you to think about the note not being done everytime you look at your e-mail in AC. Just a suggestion.

I run a fast paced urgent care clinic in a ski town. I rarely finish my notes at the time of discharge. In order to use the encounter billing form that I do like, I first put in my diagnosis codes for the encounter, any orders, and my discharge instructions making certain that any chargeable items are included. I then pull up the draft and print it to my front desk for them to make the bill. Then I forward the chart to my inbox to be completed later. Not perfect yet, but it does work for me.

Thanks fellas.

I think I'm going to incorporate parts of all your suggestions. It's just frustrating not having everything in sync.