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  • 1.  EHR errors, amend, delete or soft delete?

    Posted 08-12-2022 01:35 PM
    Curious to know how your organization handles EHR mistakes? Do you allow a soft delete where information is not viewable, but its kept and stored in the EHR? OR does your EHR require ammendments or addendums to note the information entered on X date and time was entered in error?

    Drafting Policy and looking for Best Practices.

    Appreciate your help! :)



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    Patsy Serna, MLS, CHC, CPCU
    Director, Corporate Compliance
    Phoenix,AZ

    Comments I share are my sole opinion and are not meant to represent my company.
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  • 2.  RE: EHR errors, amend, delete or soft delete?

    Posted 08-15-2022 08:37 AM
    HI @Patsy Serna Gonzalez,

    You could also post your question to Chief Compliance and Ethics Officers Healthcare and see if anyone in that group could weigh in:
    https://community.corporatecompliance.org/communities/community-home?CommunityKey=4e43a44d-a01e-4538-84bc-33dd0e72df8c


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    Stephen (Steve) Pavlicek | Community Engagement Manager
    Society of Corporate Compliance and Ethics
    Health Care Compliance Association
    Office: 952.567.6219 | Mobile: 612.207.3172
    6462 City West Parkway | Eden Prairie, MN 55344
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  • 3.  RE: EHR errors, amend, delete or soft delete?

    Posted 08-15-2022 03:27 PM
    Hi Patsy,

    Here are some resources to help and some comments.  Electronic systems track everything somewhere.  Even if the information is not viewable, there are system logs so I would suggest deletions are only permitted under special situations and determined on a case-by-case basis (for example - we conducted some training for electronic prescribing and someone accidentally keyed a test patient into the production system - so obviously, the Easter Bunny did not get a prescription sent to CVS - yes, that actually did happen - true story).  Deletions are rare.  Any errors should be corrected and how it is done, depends on how the situation and vendor's ability.  For example - when the physician's completed their note for a visit on an outpatient that was considered locked:  prior to a note being locked they could add corrected information into it, however, once the note was locked, a new note (addendum) had to be generated and attached to the visit.

    Medicare's resource on their program:  CMS program integrity guide (Chapter 3) section 3.3.2.5 pages 51 and 52 which essentially is the guide that reviewers for the program use.  https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf.

    When correcting or making a change to an entry, the original entry should be viewable, the current date/time should be entered, the person making the change should be identified, and the reason for the correction/change should be noted. 

    I also find that many not-for-profit, educational, and government organizations will post their policies on the Internet so you can find examples of other organization's policies through a simple Google search.  .edu, .gov, .org are all types of organizations that will publish their policies publicly.

    I hope that helps!

    Dianne




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    Dianne Koval
    Chief Operations Officer
    MedAllies, Inc.
    Highland,NY
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