Interventions: can be Edited or Undone

Notes: can be Amended or Undone

EDITING AN INTERVENTION

• You may need to edit or change your documentation from time to time 
• Edit includes: Change your own documentation, or Add to existing documentation from another user (i.e. admission assessment started by day shift nurse and finished by night shift nurse) 
• There is an audit trail that may be reviewed in the history that shows who documented which piece
• From the Worklist, click on the Last Done cell associated with the documentation you want to edit

The Detail screen defaults to the History tab which displays all activity events for the intervention

• Created - when the intervention was initially added
• Document - displays the activity date/time and user that documented
• Not Done - displays the activity date/time and user that documented the intervention as not done

• Click the Document for the date/time that you documented
• Click the Edit button at the top of the page

The intervention documentation displays

• Click on the response that needs to be edited
• Click the second Edit button at the top of the page
• Edit the Documentation
• Click Save and Exit

Note the history tab now displays Edit Result below Document

• Click Flowsheet tab to view the change
• Click the symbol to see the prior documentation and the new documentation, side by side

UNDO AN INTERVENTION

• There also will be times documentation needs to be undone
• The most common reason is because it was done on the wrong patient or wrong visit 
• This also shows in the audit trail
• The undone documentation is not visible in the EMR but can be seen in the audit and is included in the patient’s legal record

FOLLOW THE STEPS FOR EDITING, but choose UNDO AND SAVE (Instead of EDIT)

• Answer the prompt, and choose a reason or free type it in

Note that history tab now displays Undo below Document

• Navigate to the Chart and click the Nurse/Allied Health tab

Open the Note by clicking on the paper icon

• A user should never add an addendum to another user’s note, but rather start a new one. The same focus can be used.
• A user can only undo their own note             

Select either Undo or Addendum  

ADD ADDENDUM TO NOTE

• Notes cannot be edited. Instead, an addendum can be added to correct the original note or to add to the note.
• Selecting Add Addendum will populate a box above the original note.
• Click the insert icon and select Canned Text, then search and select a Focus.

• Document then Click Sign (some users will require a PIN). 

• Click Sign again on the next screen. Do NOT assign a provider.

In the chart, the Addendum will display above the original Note:

UNDO A NOTE

• Selecting Undo, enter a reason, then Save. 

• This will undo ALL information, including any addendums to that particular note. This will show as a comment in the Chart. Clicking on it will show the reason. 

• The Note will no longer be accessible to the end user.