Home Forums Discussions Problems No way to edit past encounters?

I just started trying out AC with the doctor I'm helping out, and we almost immediately made a mistake when entering an encounter. Is there no way to remove/edit this encounter? According to the help, at least, an encounter can't be edited after it's signed/saved, but this seems somewhat ridiculous, as data entry errors happen all the time.

This encounter would now be rejected from any electronic submission made, and would essentially be permanently misfiled.

Any ideas?

Thanks for any help.

Hi there, and welcome to AC. Yes this is something we have discussed for quite some time now. There is some amount of reason to have the records "locked" to show that someone didn't go back and tamper with the record. But typing is much different than hand writing. Many of us have suggested two fixes that I think should both be incorporated.
1) one frequently sees these mistakes no more than about 5 seconds after they sign the darn chart, "darn I forgot to change the date" or what have you. If corrected on the same day within a few hours or so, one should simply be allowed to change it without any record of the change. Seems I can change E&M codes with no real tracks. I do it all the time. I get the invoice days after the doc has charted the encounter, realize it should have been a CPE instead of a regular office visit and I just change it and it updates in. I can change or add Dx codes too.

2) Just as in a paper chart, docs frequently "put a line thru it" and initial the thing and then add the proper data or sentences or what have you. This is for mistakes made. But how many docs chart half the encounter on the date of service, and then finish it up later. Even go back after they thought they were done, because they honestly forgot to add one or two other subjects they and the patient talked about and nobody is the wiser and it really isn't cheating. It's really getting the record properly straight. Add to that encounter all that you really did. There is no malpractice or fraud in that. That is being accurate. And so AC needs to add features that will allow such things too.

But such is the state of the program right now. Save the charts to the provider's inbox until they are sure they really like it. Then and only then should they finally sign it. Lastly, make one or two false patients for the newbies and let them play with Brittney Spears and James Bond for awhile so when the do work on real charts they already have the hang of it. But that's another story... Good Luck and welcome.

Thanks for the extensive post, and for the welcome! I agree that it should have a time window for editing, even after signing. Ah well. I'll advise my doc to get in the habit of checking twice... hopefully this won't end up happening too often, and I'm glad it happened so early on.

Cheers,
Eric

A good way of proofreading the note before you sign it, is by hitting Ctrl-D ("Print Draft").

This is discussed in more detail in this post:

http://www.amazingcharts.com/ub/ubb...cmd&topic=0&Search=true#Post4886

I personally wish we could go back and change notes at any time, using our Administrator password, using a system where the changes were recorded in a "partially hidden" form within AC, dated and time-stamped, and we had to list a reason why we made the change, like we do when we edit a post on this forum.

Eric,
I use Dragon Naturally Speaking with my AC and have made some very creative mistakes that could probably make the Jay Leno Show. The vast majority of these were because I signed the note during a very busy day. My current custom is to complete the dictation and then forward the chart to myself. I then come back later when I am not rushed, proof read my chart and sign it.
The plus side is that I am then able to add in preventive procedures etc. to make the chart more complete as well as more professional. I totally agree with Brian that we need to ability to 'put a line through the mistake, correct the mistake and date stamp it'.
Jim

I also use Dragon, and the errors you make with Dragon are very insidious, because all the words it types are real words.

In other words, the kind of mistakes you make with Dragon are not the kind you would ever find with a spell checker. You can't just skim for typos; you have to read to make sure it makes sense.

This kind of editing is much easier in the Ctrl-D mode I described above. It takes all the text (even the hidden text that you might not have scrolled down far enough to see), and puts it in a "Print Preview" format that is easier to read, and forces you to see the text through new eyes.

If you see an error, you just close the Print Preview screen, fix the error, click into a new field, and hit Ctl-D again.

It is very fast. I can't recommend it highly enough.