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)
Once our documentation is authenticated it is considered finalized and ready for billing (we are an outpatient facility). Anything added or needed to be changed must be done through an addendum to the original. If we have documentation which is entered in the wrong chart, we void the billing, and have the vendor unfinalized the note so we can delete it (for patient safety and to avoid a potential unauthorized disclosure).
Lynn Boyes, RHIT
Health Information Management Director,
HIPAA Privacy Officer
7010 S. Yale Ave | Tulsa, OK 74136 firstname.lastname@example.org | 918.492.4135 direct line
918.494.987 fax | 918.555.9999 cell
Website | Facebook | Twitter | LinkedIn | Instagram
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
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.