Health Information Technologies & Processes

Deleted Documents

  • 1.  Deleted Documents

    Posted 01-10-2019 21:39
    What is your policy when a physician creates duplicate documents (for example a procedure or progress note)? They put all of the same information in it and then come to you because they realize they have created and signed the same procedure twice, the only difference is the time they drafted and signed it?

    Any Meditech users out there? Curious due to some of the limitations this EMR has compared to others.

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    Deanna Heinrich
    Director of HIM/Privacy Officer
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  • 2.  RE: Deleted Documents

    Posted 01-11-2019 07:01
    I always make the physician review both copies and tell me which one they are keeping. Once the do that, I get rid of the copy they didn't want.

    Victoria Maans, RHIT





  • 3.  RE: Deleted Documents

    Posted 01-11-2019 09:01

    This does happen, albeit infrequently, but our policy is the physician must contact me directly (HIM Director) and tell me which note to "cancel" and "delete".

    Donna

     






  • 4.  RE: Deleted Documents

    Posted 01-15-2019 13:09
    Given the size of our organization we have a Chart Corrections team who process requests for deleting documentation. ​We have EPIC which functions much differently than Meditech, but our providers and end-users have the ability to send us a chart correction request. We require them to be as specific as possible when referencing what document needs deletion, especially if the document is a duplicate. Then the chart correction associate validates the information provided and takes whatever action is needed.

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    Kenneth Starkey
    Supervisor, Document Management
    UMass Memorial Healthcare
    Kenneth.Starkey1@umassmemorial.org
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  • 5.  RE: Deleted Documents

    Posted 01-16-2019 11:50
    As others have stated we require the original provider who made the discussion contact our transcription team to determine which should be cancelled.  We have Meditech and we would just cancel the note.

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    Deloris Farthing
    Director, Health Information Management
    Hays Medical Center
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  • 6.  RE: Deleted Documents

    Posted 03-05-2019 17:06
    Are you then going and deleting the cancelled report or leaving that in Meditech in the event you were ever asked what was deleted if they would pull an audit on the account?

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    Deanna Heinrich
    Director of HIM/Privacy Officer
    ---------------------------------





  • 7.  RE: Deleted Documents

    Posted 03-05-2019 17:24

    In Meditech it is cancelled status and is not actually deleted as you can review the report in history or audit trail.

     

    Deloris Farthing, RHIA, CHPS, CHDA, CHTS-TR| Director of Health Information Management

    HaysMed, part of The University of Kansas Health System
    785-623-5813 | FAX 785-623-5078 | 
    deloris.farthing@haysmed.com | PO BOX 8100, Hays, Kansas 67601








  • 8.  RE: Deleted Documents

    Posted 03-05-2019 17:27
    We would delete the old report from meditech.

    Victoria Maans, RHIT