- What do you need to know about correcting EMRs?
- Further steps to take
- Common staff errors with EMRs
When mistakes happen, how should an entry in a patient’s EMR be corrected? EMRs or electronic medical records save patient data. Undoubtedly, EMRs offer us many benefits. These range from instant access to data to review a cross-section of medical reports and patient information. Yet, everything has some flaws. Because the data comes in an electronic form, you can change it easily.
Thus, procedures and policies must ensure that you watch the mistakes in medical information. And this is how you’ll be able to keep the integrity of patient information. Consequently, you should know the initial steps in applying corrections to your EMR.
What do you need to know about correcting EMRs?
To learn how should an entry in a patient’s EMR be corrected, start by accessing the EMR. Firstly, make sure that the information is an error. When you doubt the information of another doctor, speak up. So, this way, you’ll be reassured that you will not change some valid data. When it is not your mistake, you’d better ask the responsible party to change it themselves.
Secondly, add an addendum to the initial entry. Essentially, you should state “addendum on the document before correction. Be careful not to delete the original data and then rewrite it. Besides, clearly state the reason you flagged the addendum correction.
Thirdly, enter “late entry” for missing data. Sometimes, a doctor notices that nobody has documented the data fully or at all. In this case, document immediately the additional data in your EMR. Remember to add the “late entry” to the documentation before providing more data.
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Further steps to take
Now, how should an entry in a patient’s EMR be corrected?
1- The authentication of the data: Once you finish adding an addendum or a late entry, digitally sign the entry. Then you need to put your credentials and full name. Date and time are also important for the signature stamp.
2- The retrievability of an original document: A medical record of any shape is legal. Consequently, you cannot remove or make parts of an active record inaccessible. Ensure storage and accessibility of any original document (the error included).
3- Ask questions and review procedures and organizational policies: every healthcare institution has procedures and policies for handling errors in EMRs. Contact health information management to learn how to handle an error.
Common staff errors with EMRs
After finding out how should an entry in a patient’s EMR be corrected, we seek error reduction. To avoid errors, you must be aware of them first. Here are some errors your staff might be commonly made:
1- Misidentification of the patient:
One of the most common mistakes in healthcare is patient ID errors. The impact of errors in patient identification can be disastrous. Extremely, think of having a patient undergo the wrong surgery. The cost of such an error could be the entire collapse of an organization.
2- Errors in prescription
when these types of errors occur? First off, it could be an error in the entered information. Maybe, your staff wrote the correct information but in the wrong place. Or, you overlooked some flags. Not only does a prescription error lead to death and injury but also to money loss. Fortunately, you can train your users to ensure they understand the proper workflow. Therefore, reducing the error rate.
3- Errors in billing
under perfect conditions, medical billing remains complicated and requires effort. Your billing department has to know how to surf through the nuances of each insurer. Because every insurer has special claim processes. A rejection will occur if you don’t file the claim according to the payer’s instructions. Sometimes, your billing department makes the mistake of entering the wrong CPT, for example. In time, little errors in billing accumulate, and a big load of money is lost.
4- Patient data cloning
Good documentation is key to good care. Yet charting is not a favorable duty. So, staff copies and paste or clone patient data from past meetings. Notes to reduce charting time. Surely this saves time at first, but it gives you more work in time. “Note bloat” happens with cloning. By definition, it is when you have charts with blocks of text with similar data. This makes picking relevant data hard. The tracking of progress becomes harder too, and many mistakes occur.
5- Week EMR management and setup
This is the least contained all error, impacting the whole institution. By itself, an EMR is a tool. Yet when it’s well designed, you customize it and tweak it to make its usage easier. Don’t change your process to match the EMR but adapt it to suit you.
In the end, if you want to avoid it. Error, start with setup. Still, this is not solely an IT task. All in all, it’s a collaboration between IT, clinical staff, and informatics. Always pinpoint the mistake before trying to seek solutions. Of course, your EMR will work better with certified staff, and so will your practice.
If you have any questions about EMR errors or EMR in general, call Ambula Healthcare Team: at (818) 308-4108! And now discover an Ambulatory surgery center vs an Outpatient hospital!