Home Forums Discussions Problems Deleting a Mis-filed note

Ok, I'm already anticipating the answer to this question but I've got ask it anyway. The senario is that a chart has been inadvertantly opened to the wrong patient, dummy that I am, I don't notice this and complete and save my note to an incorrect patient record. So now I've got a perfectly good note saved in someone elses chart. In the paper world, you just open the chart, take out the note, put it in the correct chart. I've been told this is not possible with AC, nor is is possible to delete the note. While I understand the need to maintain the intergrety of the the electronic record, this seems like a bit of a disaster if I can not use administrative privileges to either delete or move this note. Does anyone have a suggestion or solution to this problem?

The only option is to put in addendum on the note, saying it was misfiled. This issue is common in all the major EMRs that I have used. I guess that allowing an administrative user to delete notes would compromise the medico-legal basis of the EMR. I agree that changing the location of a note isn't deleting it, but "digitally" it is still a deletion.

I am sure some type of deleting log would be a solution also.

Ah, the joys of modern tech

I say throw it on the "Wish List" to be able to do such things. Again as noted here Yes some sort of a record would and almost certainly should be made of it, but it is no more appropriate for a wrong note someone else's PHI to be in the wrong chart, no less not having it, in the correct chart....

As a matter of fact this sounds like an old conversation from many years ago and I'm not 100% sure that some solution for such a thing might not actually now be in AC....

Today especially with all this Gov't Spying and reporting in our EMR's just to be thrown a Meaningless bone or two... it would seem to me that having Bad Data in would be offensive and even BAD or Wrong... Now you are tracking and including BAD and inaccurate data.... A 25 year old women with the BP and arteries of some a smoking 75 year old male certainly doesn't do the greater gov't oversight and desire to make us all their life long test slaves any good, now does it???

Call tech support or Ping them at least and see if there might not be some solution to remove BAD, inappropriate enteries.... What if they were Identifiable in the Wrong Chart.... There should be some sort of a solution with internal tracking....

Paul

As I'm sure you know, the problem with the addendum idea is that an addendum appears at the END of the note. So you still don't know that the note is bad unless you read it all the way through to the end. If you start with a previous note as a template, as I do, this means you may unknowingly perpetuate the data from that single bad note, forward indefinitely. Now we can really talk about compromising the integrity of the medical record!

At least I would think you should be able to mark it easily so it was not included in charts when they are exported or printed. I agree with you all... BAD data should be easily identified at a minimum... the equivalent at least of drawing a big "X" over it and putting "WRONG CHART" on the note.

Yes, it is an old conversation, but no, it has not been addressed.

I agree that this is an issue; speaking of Tahoe (in another concurrent thread), it was discussed with Jon B a at that time, and he is certainly aware of the issue. Sounds like it is "on his list".

There are several potential ways to improve the way AC deals with this. I have always favored creating an option to "strike through" erroneous text, as you would do with a paper chart. If the entire note is an error, where it appears in the list of "Past Encounters", the strike through would appear there, too. In that way the error and correction would always be included in the record, but it would be clearly visible as such.
I also agree that MU has added a level of urgency to this. The current system means that everything in a note entered in error (even if it is "deleted" in an addendum) is counted incorrectly towards the MU criteria. This will mis-represent your data either in your favor OR against you, but always inaccurately.