It had to happen eventually. Doc was pressured for time, and accidentally added an addendum to the wrong chart. Is there any way to remove it? Using AC 8.3.1.
Some of us have long argued that there should be a way to address errors like this. As you note, for legal reasons it may make sense to leave the error in place. It is hard to imagine, though, why there would be legal issues with creating the ability to draw a red line through an entry that was in error to reduce confusion (and the potential for future, worse errors).
When we get errors like this, we just post another addendum stating the previous was in error. I kind of like it that way. I would rather that entries could not be edited, modified or deleted; requiring an additional note to correct. The only big issue would be that a different patients information is in someone else's file and could be transferred to another recipient at some point. Boilerplate in the addendum should protect you in this case, such as:
"The foregoing information may refer to a different patient and was inadvertently placed in this electronic record by mistake. Under HIPAA guidelines and federal law this information may not be disclosed, and if possible, should be removed from any further electronic record or transmission. If this record has been transmitted to another healthcare provider or business associate, they must protect this information as diligently as they would the intended patient record or face prosecution under federal or state law, discipline from medical boards, and damages from patients or affected healthcare providers."
Kevin Miller, MD Paradise Family Healthcare Venice, Florida
The patient in question is no longer part of our practice; when requested, we'll just print out the entire (short) record for transfer to another physician and/or to the patient directly. Then we'll add the addendum that KEVIN suggests, above, to the electronic record to cover us in case an electronic copy is required at some point. Thanks
Here's a design we have for a future release..you'll be able to void element so they do not get mistakenly sent to others but they will always remain in the patients chart as voided. No time frame on a release date yet but it's been designed
While talking about it, one thing that happens with addendum which can be extremely annoying. If you write an addendum especially a long one, then change the type, you lose everything. Workaround, copy to clipboard first. Maybe a warning.
While talking about it, one thing that happens with addendum which can be extremely annoying. If you write an addendum especially a long one, then change the type, you lose everything. Workaround, copy to clipboard first. Maybe a warning.
I logged a change request for this....It's not really a "bug" as it was designed for that but it's a poor design and should retain what you typed. Haven't had other reports on this one that I can find.
@cconrad@ac: I see no point in going through the trouble of "deleting" when you can then "show deleted." Frankly that is just a waste of time.
Most other EMR I am familiar with only allow you to place an addendum stating an entry was made in error. This makes sense. Makes you pay attention when you save, in my opinion. As a surgeon I understand this concept well. I do not get to make the cut again because I did not like the first one I made! Measure twice, cut once...
Ps: Before you go there @cconrad@ac, this is completely different from adding pages to imported items, which are not part of the EMR.
If I pull the wrong folder, put a piece of paper in it, then immediately realize it's the wrong folder - all I have to do is pull the paper out and put it in the right folder. I don't leave it there with a sticky note stating it's a mistake.
In my opinion, electronic records should work the same way. If you save something to the wrong chart and realize it immediately, you should be able to delete it. The time frame to allow that should be small - maybe just a minute or two. Anything beyond that time frame would stay in the chart and require an addendum.
Anne-Marie Family Medicine Whatever Someone Else Isn't Handling Manager
I know they probably do it to keep people from tampering with charts, but that safeguard for the lawyers was never in place with paper. You were on your honor not to tamper with something. I think it should work like a paper chart, and the safeguard could be entering admin password and logging it.
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