I hear ya, and in my mind I hear my Pa saying: 'Just 'cause it can be done doesn't mean it is a good idea.' 🙂
I would strongly advise against any alteration of the record that is not native to the EMR's functionality. There are unforeseen consequences if it is ever detected (and don't even think it, no one is that good).
While state laws vary, if an organization receives federal money, federal law is the rule of the day. Federal law has very specific guidelines regarding medical documentation. In short, modification is grounds for, at minimum, doubt in a malpractice suit or claim dispute, enough doubt that it is nearly impossible to defend and win; at most, it is a conspiracy to conceal/alter evidence with real penalties and fines associated with it.
I urge every Medical IT job description to become well versed in the medical-legal statutes, at both the Federal and State level. The medical field demands that all who contribute to it understand and abide by certain rules otherwise the risk of patient harm, loss of revenue, and/or loss of reputation will be the outcome.
This ain't Google or Facebook, it is human life and missteps have real life consequences.
The following excerpt is something to ponder if you have taken a different approach and it is actually on topic for the original post:
http://www.medscape.com/viewarticle/809517
Question:
I work in an operating room, where we have EMRs. We check each other's charts for mistakes, sometimes days later. We are told to make corrections if we find mistakes. Is this legal?
Response from Carolyn Buppert, MSN, JD
Healthcare attorney, Boulder, Colorado
It's good that you are doing internal audits -- staff learn by analyzing what they are doing right and identifying what they need to improve. It is legal to correct mistakes and make late entries, if it is done appropriately. If not done correctly, it could be illegal and, at minimum, more detrimental than helpful.
With your correction, you need to make it clear that the entry is a late entry and that you are correcting a mistake. You should not try to eradicate the erroneous previous entry. You should not try to make the new entry appear to be the original entry. First, know that there may be state laws that apply to this situation. Hospitals should have policies on how to correct errors in the medical record. Your hospital's legal counsel should be in on the discussion about the policy, should review the state law, and should review the policy.
In general, the appropriate way to correct an error is the same as with paper records -- that is, make a new entry with today's date and time, stating that you are correcting an error in a previous entry; give the date and time of the previous entry; and enter the corrected data or explanation. Without knowing the details of your electronic record, I can't say exactly how to accomplish this, but what you want is for the original entry to be visible, with a notation that alerts a reader that this part of the record has been corrected and directing the reader to the corrected information. The original author of the report should be the individual making the correction. If someone else is making the correction, the new author should explain why he or she is making the correction.
The reason for keeping the original entry is that if there is a challenge to the care or the documentation (for example, a lawsuit filed or a claim for reimbursement rejected), the hospital and clinicians need to avoid any indication that the records have been altered in anticipation of litigation or payer audit. Alteration of records (sometimes called "spoliation of the evidence" in a legal proceeding) is detrimental to the defense of a malpractice action or a claim for payment. The opposing party is entitled to an assumption that the altering party had a "consciousness of guilt." Defense attorneys say it is nearly impossible to defend a hospital in a malpractice case when the record has been altered.
A Website for nurse legal consultants tells attorneys to be alert to signs of tampering with medical records. "Tampering with the record involves any of the following: adding to the existing record at a later date without indicating [that] the addition is a late entry, placing inaccurate information into the record, omitting significant facts, dating a record to make it appear as if it were written at an earlier time, rewriting or altering the record, destroying records, or adding to someone else's notes."[1] If records are altered in anticipation of a payer audit, then the payer, when discovering the alteration, presumes the hospital or clinician has billed fraudulently.
The bottom line is that internal audits are good. When mistakes are identified, focus on educating the clinician about his or her error and how to document better in the future. In general, correcting errors found during internal audits should be done rarely and carefully, without intent to deceive.
Posted : August 8, 2017 3:32 pm
