Health Information Technologies and Processes

EHR incomplete electronic orders

Chelsea R Bemiss, Health Services Administration,RHIA06-26-2019 12:59

Donna L. Crew, RHIA,President Elect AAHIM 2019-202006-27-2019 09:17

Loritta M. Black, Health Information Management,RHIA,CCS,CHTS-IM06-27-2019 10:37

Ashley Andrews Dean, Bachelor of Science,CHDA,CPHI,CPHIMS CPPM CPC07-02-2019 11:37

Kara L Lusa, Health & Medical Informatics,Computer Forensics &08-08-2019 05:52

Donna L. Crew, RHIA,President Elect AAHIM 2019-202008-08-2019 09:06

Sharon L McGraw, RHIA,MS, ICD10- CM/PCS Train-the-Trainer06-27-2019 12:55

Sharon D Scott, Health Information and Health Informatics,RHIA15 days ago

  • 1.  EHR incomplete electronic orders

    Posted 06-26-2019 11:44
    ​Does anyone have a policy regarding pending deficiencies on their EHR? Scenario - multiple incomplete signatures in the EHR, some of these are physicians no longer active in our system and some are where staff have chosen the incorrect physician or a non-active physician. These pending orders still show on a electronic deficiency letters. Our EHR vendor (Cerner) has suggested to set a rule that the system will  sign off on these after 365 days.. The order would show as "administratively signed".

    How do you handle unsigned signatures/documents in your EHR? Do you have a policy you are willing to share?

    Thank you for your time!

    Kay Butcher

    ------------------------------
    Kay Butcher
    Director of Health Information Mgt.
    SJMH
    ------------------------------


  • 2.  RE: EHR incomplete electronic orders

    Posted 06-26-2019 12:59
    I have a policy that I am willing to share. What is your email?

    ------------------------------
    Chelsea Bemiss
    System Director of Him
    Ephraim McDowell Regional Medical Center
    ------------------------------



  • 3.  RE: EHR incomplete electronic orders

    Posted 06-27-2019 09:17
    Would you email me a copy?
    Dcrew'@rmccares.org
    Thank you​

    ------------------------------
    Donna Crew
    Directorof His/Privacy Officer
    ------------------------------



  • 4.  RE: EHR incomplete electronic orders

    Posted 07-02-2019 13:45
    Would you email me a copy as well.

    Mary Beth McF  at  RRA2nursinghomes@aollcom





  • 5.  RE: EHR incomplete electronic orders

    Posted 06-27-2019 09:25
    ​Hi,
    We have had a significant problem with this as well.  Would you mind sharing your policy with me too?  lboyes@crsok.org
    Thank you,

    ------------------------------
    Kathryn Boyes
    Director, HIM
    ------------------------------



  • 6.  RE: EHR incomplete electronic orders

    Posted 06-28-2019 01:18
    We have this issue at our facility as well and we are in discussions now on what to do. This policy would be helpful. Can you send me a copy as well. Jill.pennala@nahealth.com

    Thank you

    Sent from my iPhone




  • 7.  RE: EHR incomplete electronic orders

    Posted 06-27-2019 10:37
    ​We have a process in place where we will manually administratively close (sign) the orders if we have exhausted efforts to get the orders signed and have received approval to close through the applicable hospital medical quality or executive committee. Additionally, to take a preventative approach, we now have nursing leadership working the declined/refused orders and this helps with accountability of nursing/clinical staff who make data entry errors such as assigning to the incorrect physician.

    ------------------------------
    Lori Black, RHIA, CCS, CHTS-IM
    HIM Director
    INTEGRIS Health
    ------------------------------



  • 8.  RE: EHR incomplete electronic orders

    Posted 06-27-2019 12:48
    I think I have sent it to all of those who have asked.

    ------------------------------
    Chelsea Bemiss
    System Director of Him
    Ephraim McDowell Regional Medical Center
    ------------------------------



  • 9.  RE: EHR incomplete electronic orders

    Posted 06-27-2019 14:45
    Interested in this too.

    Sent from my iPhone




  • 10.  RE: EHR incomplete electronic orders

    Posted 06-28-2019 11:02
    ​Could you please send me  copy also?  Thank you
    madeleine.sanders@overlakehospital.org

    ------------------------------
    Madeleine Sanders,
    Manager of Health Information Services
    Overlake Hospital Medical Center
    Bellevue, WA
    ------------------------------



  • 11.  RE: EHR incomplete electronic orders

    Posted 06-29-2019 07:25
    I would be interested in the policy as well. Thanks for sharing!
    Sue.nathe@tchc.org


    Sue Nathe
    Sent from my iPhone
    Confidentiality Notice: This e-mail and any attachment(s) may contain confidential information that is legally privileged. This information is intended only for the use of the addressee named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless required to do so by law or regulation. If you are not the intended recipient, you are hereby notified any other use, disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this transmission in error, please notify the sender immediately, reply to this transmission, or contact the Tri-County Health Care Privacy officer at (218) 631-7504 and delete these documents.




  • 12.  RE: EHR incomplete electronic orders

    Posted 06-30-2019 11:54
    I, too, would appreciate a copy.
     
    Thank you
    Jeannine Kimble|HIM Manager
    Lane Regional Medical Center
    Revenue Cycle Department
    Jeannine.kimble@nthrive.com
    225.658.4275
     
     
     





  • 13.  RE: EHR incomplete electronic orders

    Posted 06-29-2019 07:47
    Would you please send me a copy too. Thank you.
    teresa.allen@volstate.edu

    ------------------------------
    Teresa Allen
    Assistant Professor
    Volunteer State Community College
    ------------------------------



  • 14.  RE: EHR incomplete electronic orders

    Posted 07-02-2019 13:47
    I would love a copy as well.

    RRA2nursinghomes@aol.com

    Thanks

    Mary Beth

    ------------------------------
    [Mary Beth] [McFadden]
    [RHIA LTC Consultant]
    [PA]
    ------------------------------



  • 15.  RE: EHR incomplete electronic orders

    Posted 07-01-2019 09:18
    Would you mind sending me a copy too?   Thank you.   cschreiner@grahamhospital.org

    ------------------------------
    Cynthia Schreiner
    Director, Health Information Management Department
    Graham Hospital
    ------------------------------



  • 16.  RE: EHR incomplete electronic orders

    Posted 07-02-2019 11:37
    I'd like a copy, as well, if you wouldn't mind!  :)
    aandrewsdean@gmail.com

    Thanks much!

    ------------------------------
    A. Andrews Dean
    Health IT & EHR Optimization Consultant
    ------------------------------



  • 17.  RE: EHR incomplete electronic orders

    Posted 07-01-2019 13:09
    Hello,
    Can you send me  a copy as well.
    cecilia.mendoza-wong@csulb.edu

    Thank you for sharing,

    Cecilia

    ------------------------------
    Cecilia Mendoza-Wong
    Health Information Technician
    ------------------------------



  • 18.  RE: EHR incomplete electronic orders

    Posted 07-11-2019 10:27

    Hi Chelsea, if you don't mind I would like it as well. My email is kviruet@valleyhealth.com.


    Thank you!


    Karla

     






  • 19.  RE: EHR incomplete electronic orders

    Posted 07-11-2019 13:14
    Hi Chelsea, May I have a copy as well.
    mindy.morningstar@clarkretirement.org

    Thank you very much

    ------------------------------
    Mindy Morningstar
    HIM / QA Analyst
    ------------------------------



  • 20.  RE: EHR incomplete electronic orders

    Posted 07-11-2019 14:56

    Yes, I would like a copy too please. 

     

    Lynn Boyes, RHIT

    Health Information Management Director,

    HIPAA Privacy Officer

    7010 S. Yale Ave | Tulsa, OK 74136
    lboyes@crsok.org 918.236.4135 direct line

    918.499.1598 fax

    Website Facebook  Twitter LinkedIn | Instagram

     

    A close up of a logo  Description generated with very high confidence

     

     

     






  • 21.  RE: EHR incomplete electronic orders

    Posted 07-11-2019 19:28
    Hello Chelsea,

    Can you email me copy of your Policy

    email: cecilia.mendoza-wong@csulb.edu

    Thank you

    ------------------------------
    Cecilia Mendoza-Wong
    Health Information Technician
    ------------------------------



  • 22.  RE: EHR incomplete electronic orders

    Posted 08-08-2019 05:52
    I’d like a copy too, please!!

    ---------------------------------
    Kara Leonetti Lusa, MS, BS
    Lead for Health Information Management
    & HIPAA Privacy Officer
    United Counseling Service
    Bennington, VT
    ---------------------------------





  • 23.  RE: EHR incomplete electronic orders

    Posted 08-08-2019 09:06

    Chelsea Bemiss have you sent the copy of your policy out yet?

     






  • 24.  RE: EHR incomplete electronic orders

    Posted 08-08-2019 10:21

    I would like one also. Please send to kviruet@valleyhealth.com

     

    Thank you!

     






  • 25.  RE: EHR incomplete electronic orders

    Posted 2 days ago
    please send me a copy Dcrew@rmccares.org

    ------------------------------
    Donna Crew
    Directorof His/Privacy Officer
    ------------------------------



  • 26.  RE: EHR incomplete electronic orders

    Posted 06-27-2019 12:55
    Hello
    I would like a copy of the policy as well
    thanks
    Sharon McGraw, MS, RHIA

    ------------------------------
    Sharon McGraw
    Director, Him
    Sampson Regional Medical Center
    ------------------------------



  • 27.  RE: EHR incomplete electronic orders

    Posted 06-27-2019 17:54
    ​Hi, Kay - we also utilize Cerner.  Our policy is to review pending deficiencies that do not get signed off due to the provider no longer being avaialble to sign. If the provider is still on staff, we expect the provider to take action.  We have a process to administratively close those documents, which is done by a delegated staff member or leader, and we include a scanned document of Admin Closure in the patient encounter.  We do not use an automated process.

    ------------------------------
    Jami Woebkenberg, MHIM, RHIA, CPHI, FAHIMA
    Sr. Director, HIMS Operations
    Banner Health
    ------------------------------



  • 28.  RE: EHR incomplete electronic orders

    Posted 08-07-2019 13:25
    I would also like a copy of this policy as well. Does this apply for orders and provider documentation? We are having an issues with providers leaving documents in draft status. thank you!

    ------------------------------
    Lin Prosper
    Him Supervisor
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  • 29.  RE: EHR incomplete electronic orders

    Posted 16 days ago
    Please send me a copy as well; carol.smith@cumberlandcg.com.  Thanks.

    ------------------------------
    Carol Smith
    Executive Consultant
    ------------------------------



  • 30.  RE: EHR incomplete electronic orders

    Posted 15 days ago
    I would like a copy of that policy and procedure as well.  Would you please send it to me at sscott@evergreentreatment.org

    ------------------------------
    Sharon Scott
    Clinical Informatics Specialist / Privacy Officer
    ------------------------------



  • 31.  RE: EHR incomplete electronic orders

    Posted 5 days ago
    Hi Kay.  Having worked on several Cerner implementations.  I recommend having a policy and process in place to manually administratively close these pending deficiencies,  Waiting 365 days will have your deficiency rate excessively high.  I would also have some type of continuous education for those individuals that are choosing the incorrect physician when entering a deficiency.  If you are having this issue with orders, also engage your clinical management teams.

    Jamika Duncan, DHSc, MHSA, RHIA
    EMR Implementation Consultant

    ------------------------------
    Jamika Duncan
    Him Applications Analyst/Consultant
    ------------------------------