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Topic starter
Is there a code that would automatically update Medications, etc. in a form after a document has been placed on hold, other medications have been entered and signed off in the chart, and when the document is reopened, the Medications, etc. would be visible in the held document?
I've tested this out myself but placing a document on hold, adding and signing off a new medication using a Chart Maintenance document, and then going back to the Held document to see if the medication was added, and it was not visible.
Any guidance on this is greatly appreciated!
Bonnie
Posted : July 16, 2018 6:10 am
If I understand what you are saying, an update doesn't typically show information timestamped after it was started, only before. Your Chart Maintenance document's clinical date is after your on hold update. You can code around some of this by writing functions that look at MEL objects.
Posted : July 16, 2018 10:07 am
There is a consistent process for everything in GE Logician - only things that occurred prior to the start of the encounter/document are visible. As David said, there are ways to get around this, however the rule (and logic) is in place to prevent something appearing in a note that you may not have previously noticed.
In your instance, a doctor starts a visit and sees medication list as it existed at the start of the visit. He/she provides care based on that info. And while it may take a few days, that same list of medications is all that was officially acted upon, and then the document is signed. Now imagine if the med list was updated on day +3 after visit, but before signing - it would appear that the doctor knew about the medication that was added after the office visit date. Thus, medication list (and just about everything else) in a note only include items that were known when the encounter is started.
Thus, when you think about it this way, it does make sense.
Posted : July 17, 2018 12:15 am
Topic starter
What my client is concerned about is if medications are entered and signed after an initial assessment took place and an initial assessment document is placed on hold, they won't be able to see the new information in the held document when they reopen it. When they go back to complete the document, they want to be able to see the new information.
Is there any way to accomplish this? David Shower - You mentioned that you can code around some of this by writing functions that look at MEL objects. Can you provide an example?
Posted : July 17, 2018 1:04 am
I would STRONGLY recommend that the client consult their legal representation. What they are asking for is against historical method and local community standards. As such, the door for malpractice litigation is wide open. Understand that malpractice law has not kept pace with the IT revolution regarding medical documentation and as such, like it or not, that is what will be used to try a case.
As stated previously, the document is a snapshot in time. It is a representation of what was known at the time of documentation. If a provider opts to extend the documentation beyond the departure of the patient (technically inappropriate since all documentation 'should' be completed before the patient leaves) and updated information is available, the proper method (and the way it was done in the paper chart days) is to start a new update or addendum reflecting the desired information (recommend finishing and signing the previous note first, of course).
Any deviation from this method, regardless of how well meaning, could easily be classified as 'fraud' in a malpractice case since it does not conform to medical-legal documentation standards (hint - even EMRs do not permit this for the very same reason).
Again, I would urge your client to seek advice from a quality malpractice attorney and or their malpractice insurance rep.
Hope this helps.
Posted : July 17, 2018 7:17 am
