Future State Wave 1 Hospitals

Recommend one policy that includes editing, amending and undoing.  This policy will cover all nursing and allied health documentation completed in MEDITECH PCS, EDM and SUR. 

A separate policy will include all provider documentation completed in Web Acute and Web ED.

Purpose

The purpose of this policy is to outline the procedure for altering clinical documentation within a patient’s electronic medical record (EMR).  Any altered documentation, though it may no longer be viewable to health care providers will remain as part of the patient’s legal record.

Definitions

Amending 

Making minor changes to the text in order to make the documentation more accurate.

Editing

Correcting an error or adding an omission to the documentation in order to make the original entry accurate.

Undoing

Removing the documentation in its entirety as it was entered in error and does not apply to the patient or was entered on an incorrect account for that patient.  The original documentation will no longer be viewable to the health care provider.  A permanent copy of the original entry is always part of the patient’s legal record, and will be available as needed.

Procedure

Interventions are edited and undone, and notes are amended or undone.  The standard timeframe to make corrections to documentation is 48 hours.  If corrections are required to be made outside this timeframe, the manager/supervisor must be contacted and a request must be submitted to Clinical Informatics or site specific delegate via Help Desk  to provide permission and allow access to the documentation. 

To edit an intervention the health  care provider will select the intervention from the worklist and select the “View/Edit” footer button.  Once inside the intervention the correction can be made or omission can be added.  Once the intervention is saved the previous incorrect documentation will be replaced and any new information added will appear within the intervention. Previous documentation will not be immediately viewable but can be accessed using the History routine.

Health care providers can only edit their own documentation, and will have the ability to edit the admission assessment and some allied health documents.

To undo an intervention, the health care provider will select the intervention from the worklist and select the “Detail” footer button. Via the “History” tab, the care provider can choose the document to be undone.  Select the “Undo & Save” footer button, the health  care provider will then be prompted to enter a reason for the undo.  The intervention will not appear within the EMR.

To amend a note the health care provider will select the Notes tab and locate their note within the list then click the notes Focus within the “Text” column.  They will then select the “Amend” footer button, a text box will appear allowing them to enter the addendum.  The original documentation and the addendum will be visible within the EMR.

To undo a note the health care provider will select the Notes tab and locate their note within the list.  They will then select the “Undo” footer button.  They will be prompted to enter a reason for the undo. Once this has been saved the note will remain in the Notes list but will be identified as cancelled and will not be viewable.

In the case that the original health care provider is unavailable to make the correction a designate can be provided access to edit, amend or undo the documentation.  A note must be made in the patient’s record reflecting the reason the designate altered the documentation.

Discharge Documentation 

Documentation can be edited for a discharged patient up to 72 hours after discharge.  If additions or edits  are required to be made outside this timeframe, the manager/supervisor must be contacted and a request must be submitted to Clinical Informatics or site specific delegate via Help Desk  to provide permission and allow access to the documentation. 

References

North Bay Electronic Documentation: Purpose and Principles for Use

Sault Area Hospital Clinical Documentation X-20

Standards of Nursing Documentation for Registered Nurses and Registered Practical Nurses in Ontario, 2008

UHN Policy and Procedure Manual- Clinical Documentation

Stakeholders Review