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Correcting an error in a locked document

michelew 11 months ago in Clinical Charting Module updated by cwaldochwa 10 months ago 9

When you have locked a document in the clinical charting, and notice an error later, what is the procedure you use to correct the error?

Interested in seeing responses on this.

A Champion user can unlock the note. Once unlocked, the note can be fixed.

Thanks Tanya, I can go in and unlock, fix, and relock, and this works well if you notice it the same day.  But if you notice this the next day, unlock, fix, relock, the relock puts the new day, not the original.  Some documents are day sensitive and changing the day even by one day, makes you out of compliance.

Anyone with the appropriate Unlock privilege can unlock the document, or portion of document, that they are authorized to unlock.

Note that Locking and Signing (which locks the (portion of) the document) are two different things.  

Some documents can be Locked without being Digitally Signed.  

Digitally Signing a document does lock (whether a portion, or ALL of) it.  

HOWEVER, any change of an unlocked document, followed (presumably) by re-signing-and/or-locking the document *may* require a Before/After notation depending on various insurance panels (or company?) requirements, if the note was "published", etc.  Just be aware of any of those requirements that may exist, and act appropriately.

Thanks for the response.  I know how to lock and unlock, but when I relock the date changes of the original signature.

We have certain day a document needs to be completed per regulation.  At times, we have completed, signed and locked the document on the correct day.  However, in the next few days someone  reviewing the document may notice an error or an omission that needs to be corrected.  Example, the original note states "client attended session for 60 minutes", the next day when reviewing you see this and the client actually only attended 30 minutes.  In handwritten notes, we would then either put a line through or circle the 60 minutes, write error, write the correct 30 minutes,  date it and initial that area.  In the electronic Procentive document If we unlock to go in and address this error in some manner, when you sign and relock, the new signature and date are reflected and the old one is gone.  In the above example, that would make the document one day late and out of compliance.

I am wondering what others are doing to correct these "errors" or "omissions" with there day regulated documents?

Hi All!

We do recommend saving a PDF of the original print view with signatures.  Since the print view will show the original signature dates.  Then attach that PDF to the online version.  After that is completed, then unlock the document, correct the error and resign.  

Likewise, you could make a copy of the document and note that it is the amended version and attach a copy of the original print view to the amended version.

Hope this helps!

Thanks Chris, that idea would definitely work, but seems quite labor intensive.  Is there anyway you can leave the original dated signature in place on a document once unlocking it, correct the error, and then sign a different line, and indicate something such as "amended" date?

We use the process Chris mentions above - to track the original (billed) document and the correctly completed document - but we upload the originally billed note to a Miscellaneous Note with a title explaining why there is a duplicate - and use the date of the service as the date of the Miscellaneous Note to keep it chronologically in order with the service line date.

cwaldochwa - I understand what you are saying about it being labor intensive, but to correct an error we have found it is better to have done too much, sometimes, to make sure we've covered every angle in case of an audit.

Thank you Sarah, I appreciate the response.  That is probably the best route then.  Unfortunately it doesn't happen that often.  Colleen