Best Practices to Modify Electronic Health Records While Maintaining Record Integrity

Moving to an electronic health record system can make it possible to work more efficiently and effectively by automating certain tasks and making information easier to locate. But sometimes, even electronic records must be modified by adding, amending, correcting or deleting information. In some ways, paper records were easier to deal with, as incorrectly filed documents could simply be re-filed, and any changes to previously written documentation were oftentimes clear and obvious. With an EHR, making changes can be both too difficult and too easy, depending on the changes desired. A simple mistake in data entry may be nearly impossible to remove, and changes that may be improper, such as changes in diagnosis or condition after the fact, might be undetectable and unauditable. Maintaining record integrity can be a difficult task in an EHR. This OnDemand Webinar will help you ensure that you have the right practices in place to ensure the integrity of records. Issues of creating a sound legal record are discussed, and the impacts of not maintaining record integrity are explained. The program covers the kinds of changes that may be made and issues each kind can create. The necessary policies and procedures are discussed, and the necessity for having such procedures is explained. Failing to have a proper process for handling changes to EHRs can leave your practice open to violations of HIPAA, adverse summary judgments in the case of lawsuits and electronic discovery, and other violations of practice and records management regulations. This program is critical for medical offices to ensure the Electronic Health Record is used properly and will accurately reflect the facts of the encounters recorded and the history of the documentation.

Authors

Agenda

Issues in Modifying Electronic Health Records

• Moving to an EHR Means Creating a Sound Legal Record
• Changes May Be Made Easily
• Changes May Be Hard to Detect
• Modifications May Be Necessary for a Variety of Reasons
• Downstream Impacts to Other Systems and Providers

Modifications, Concerns and Guidelines

• Addendums
• Amendments
• Corrections
• Deletions and Retractions
• Late Entries
• Requests From Individuals

Policies and Procedures

• Necessity for Establishing Clear Practices
• Matching Paper and Electronic Procedures and Results
• Sample Policy Contents

Resources

• AHIMA
• AAFP
• ASTM

Additional Formats