Health Information Technologies and Processes

Locking of documentation

  • 1.  Locking of documentation

    Posted 05-17-2019 10:32
    ​We are looking to implement a setting in our electronic health record that would lock documentation for editing 60 days after final signature. If a provider wants to make a change after the document is locked they would have to call HIM to request it be unlocked. I'm interested in knowing if other organizations do this and if so what is yours set at? Also, how did you present this to your medical staff in order to get their buy in? Ours was not very receptive to the idea.

    Thank you.


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    Susan Kufahl, RHIT, CHPS, CHDS
    HIM Operations Coordinator
    Fort HealthCare
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  • 2.  RE: Locking of documentation

    Posted 05-17-2019 10:57

    For our clinical staff such as RN, RCP, Rehab, etc. have only 3 days after discharge to complete their documentation.  (After that, they have to contact their Manager who then contacts the IS Department to "open the electronic record")    

     

    We do not lock out Physicians unless I receive notification it is a legal case; then I "seal the electronic record" and it is not accessible for anyone to see or edit. 

     

    Any additional documentation any one enters is obviously electronically date stamped/time with current date.   (becomes part of the audit trail)

     

    Donna

     






  • 3.  RE: Locking of documentation

    Posted 05-17-2019 11:45
    ​Our EHR encounters lock after 10 days.    There has been some discussion over the past year about why, and how soon they lock, These conversations have been initiated by physicians who prefer that the encounters don't lock at all, or the time frame is extended past the current 10 days.   Ten days is our hospital policy.  Myself, as well as our IT Director have stood firm in leaving the 10 day lock as is.   Although it usually creates the largest burden on my HIM staff, as we are having to continually unlock encounters for a few of the docs who are chronically late with completing their documentation.

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    Karen Evans
    Him Director
    Yuma District Hospital
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  • 4.  RE: Locking of documentation

    Posted 05-20-2019 12:35





  • 5.  RE: Locking of documentation

    Posted 05-17-2019 11:00

    Our IP records are locked 16-days post discharge, and OP encounters are locked after the encounter has been completed closed/not more than 30-days. These requirements were implemented when we went live with our systems-wide EHR six years ago. Documentation changes to the record can occur at any time after the closure by following documentation change processes (addendum, corrections, amendments, etc.).

     

    ______________________________________________

    Maria C. Alizondo, MOL, MLC, RHIT, FAHIMA

    Director | Enterprise Health Information Management Services

    ISS | Information Services & Solutions 

    Office: 310-267-7603 | Cell: 818-590-7504

    mcalizondo@mednet.ucla.edu

     




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  • 6.  RE: Locking of documentation

    Posted 05-17-2019 12:33

    Hi, we do not allow any edits to documentation once signed. All are entered as addenda to the original documents. We have a system default set to 45 days for any new documentation to arrive to the medical record once the patient is discharged.


    Thanks,

    Karla

     






  • 7.  RE: Locking of documentation

    Posted 05-17-2019 14:23
    ​Good Afternoon,

    The integrated health system I work for is an Epic shop. We have parameters set in Epic to lock the chart after 7 days for most general caregivers. Providers have a longer lock timeframe which I think is 90 days. After that timeframe any edits to the chart need to be made on computers located in HIM department designated as chart corrections computer.

    Warm Regards,

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    Sarah R. Keppen RHIA
    Applications Analyst
    Facilitator Certification Exam Prep Community
    2016 Chair Engage Advisory Committee
    skeppen@regionalhealth.com
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