Confidentiality, Privacy & Security

1.  Deleting from the e-record

Posted 11 days ago
Currently, we are removing, ie. deleting documents from the e-record and electronically placing them in the patient’s DMS file in a Folder titled Void. Documents being ‘deleted’ may be blank due to an incorrect document being selected by the clinician or may be a document that was dated incorrectly (e-record doesn’t allow changing the date) and will be rewritten using the correct date. Also we have deleted partially completed documents which were started using the incorrect form.
When we delete, we document the deletion by listing the name and date of the form, who requested the deletion, the reason for the deletion and the date the deletion occurred. That explanation is scanned to the DMS folder with the actual document that was ‘deleted.
My question:
1. Do you delete from the e-record?
2. Do you only keep the explanation for the deletion or do you also keep the actual document you deleted?
I feel that if we have a copy whether it’s in a VOID folder or elsewhere, it really isn’t deleted and we’d have to produce it unless we identify that DMS VOID folder as not a part of our designated record set.

Sent from my iPad


2.  RE: Deleting from the e-record

Posted 11 days ago
Pamela,

My organization limits who can delete scanned images from the record.

In our system, Evident, you select the document to be deleted from the scanned images section attached to that account.  You select a reason for deletion (e.g., upload error, incomplete scan, wrong account) and then delete the image.

The image remains on the account but only accessible by certain users, such as myself or the director of HIM.  A log of each image is maintained by the system to show who deleted it, why it was deleted, and who viewed it after deletion.

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Jesse Floyd, RHIA
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3.  RE: Deleting from the e-record

Posted 11 days ago
​Hi Pamela,

This topic is something I've been working on since we started with our EHR last April.  I would like to "Void" or "Hide" mistaken chart entries such as you described-actual mistakes that should not be in the chart-as opposed to mistaken entries that should be appended as errors.  We currently do not have this functionality.

I do keep a log of alterations I may make to the electronic charts...such as putting final documents back into draft status,  moving a note entered into an incorrect patient episode to the correct episode, and merging records.

What is the patient's DMS file?

I wonder if during a Joint Commission survey we would be required to reproduce the "removed" documents?

Thanks,
Teri

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Teri Smith
Health Information Administrator
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