Health Information Technologies and Processes

in-error documentation in EHR

  • 1.  in-error documentation in EHR

    Posted 05-21-2020 20:55
    Hi all-

    I'm curious to know how other facilities handle the in-erroring of documentation from the EHR? Do you allow for folks outside of HIM to remove documentation? If so, do you have any limits? For example, only allowing the in-erroring of documentation you authored, or limiting by position level, restricting by specific areas, etc.

    Thanks everyone for the feedback!

    Karen Reynolds
    Director, Health Information Management
    North Kansas City Hospital

  • 2.  RE: in-error documentation in EHR

    Posted 05-22-2020 10:33
    Hi Karen,

    At my facility only certain people have access to move, unsign or cancel documentation. I'm currently at the start of the process of creating a chart correction policy and procedure because before my arrival, there wasn't much documented as to the reason for unsigning or moving the documents. Currently only myself, my transcription supervisor and 2 IT analysts have the ability to touch documents.

    Hope this helps!

    Glenda Rakes MHIIM, RHIA
    HIM Director/Privacy Officer
    Northern Montana Health Care

  • 3.  RE: in-error documentation in EHR

    Posted 05-26-2020 14:17



    HIM is the only department allowed to edit/delete scanned documents. Typically we try to avoid deleting altogether. We use an "original" document version and move it to that part of the medical record.





  • 4.  RE: in-error documentation in EHR

    Posted 05-27-2020 08:14
    We have created a " Removed Forms" section in our EMR.  HIM moves it there and it is only visible to HIM staff.

    Stacey Goodenough
    Manager of Medical Records / Privacy Officer
    Wayne Memorial Hospital

  • 5.  RE: in-error documentation in EHR

    Posted 06-22-2020 20:24
    Hello Karen,

    Our organization allows the staff outside of HIM to "in-error" only the documents they authored while HIM staff can modify or in-error all scanned docuements.

    Debra Messersmith
    Data Integrity Analyst