Text Integration Utility (TIU) - Correcting Documents Entered in Error EHR for HIM

Deleting a Document Entered in Error A note has been entered in error. The author writes an addendum to the note requesting the note be removed from the patient’s record You receive the call to delete the note and the attached addendum This can be done in either TIU or EHR

Deleting a Document, cont. This places it in a retracted status and unavailable to everyone except the Chief MIS/HIM, CAC, and other designated personnel through the ASU Business Rules

To Delete the Document in EHR Open the note in EHR Right click or select “Action” menu Select “Delete progress note” You will see the following:

In this example, I chose Administrative Action because I am deleting the note due to the author entering it in error Select “Yes” on the confirm deletion screen The following message will display:

Correct/Amend a Signed Document Amending is when the facility has agreed to a patient’s request to correct/amend their health information under the HIPAA Privacy and Privacy Act. For example, a patient requests erroneous information be removed from a note.

Correct/Amend continued While viewing a note in TIU, select the action “Amend” You will be prompted to enter your signature code The TIU Editor will allow you to make edits The original note will be retracted and the new note will have a status of Amended

Example of Amended Note DATE OF NOTE: JUL 13, 2004@16:42 ENTRY DATE: OCT 19, 2004@18:13:17 AUTHOR: ZIPPER,KIMBERLY RN EXP COSIGNER: URGENCY: STATUS: AMENDED SUBJECT: test ztest /es/ KIMBERLY ZIPPER RN Signed: 07/13/2004 16:42 10/19/2004 18:13 AMENDMENT FILED:

Reassigning Documents The reassign action reassigns a note to a different patient, admission, or visit The reassign action may also be used to promote an Addendum as an Original, swap the Addendum and the Original

Who Can Reassign Documents? Reassigning completed documents is usually restricted to a specific User Class, for example, Chief, MIS This includes notes that are awaiting co-signature Unsigned notes may be reassigned by the Author/Dictator

The basic reassign process includes the following steps: 1. Electronic signature challenge. If the document is already signed, TIU asks for the electronic signature of the Chief MIS. 2. Retract. If the document is moved to a different patient, TIU retracts the document. 3. Re-edit original visit. If necessary, the PCC information is updated for the original visit. 4. Edit destination visit. If necessary, PCC information is collected or revised for the new visit. 5. Sign. The original provider needs to sign the document. If the document was moved to a different patient, TIU removes the original signature. The receiving provider needs to sign that note.

Unsigned Note Transferred from One Patient to Another This menu option is accessed from the BTIU Menu 2. You will require keys (TIUZHIS and TIUZVSIT) to use this menu option. Select OPTION NAME: TIU MAIN MENU MGR Text Integration Utilities (MIS Manager) --- MIS Managers Menu --- 1 Individual Patient Document 2 Multiple Patient Documents 3 Print Document Menu ... 4 Search for Selected Documents 5 Statistical Reports ... 6 Unsigned/Uncosigned Report Select Text Integration Utilities (MIS Manager) Option: 1 Individual Patient Document Select PATIENT NAME: car 1 TEST, PATIENT 4-2-44 123549876 YES NON-SERVICE CONNECTED THIS IS A TEST 2 ZTEST,MALE 4-1-48 123456789 NO NON-SERVICE CONNECTED CHOOSE 1-4: 2 ZTEST,MALE 4-1-48 123456789 NO NON-SERVICE CONNECTED THIS IS A TEST (1 note ) C: 03/16/99 10:20 Available documents: 11/23/1998 thru 01/19/2001 (19)

Example continued Please specify a date range from which to select documents: List documents Beginning: 11/23/1998// <Enter> (NOV 23, 1998) Thru: 01/19/2001// <Enter> (JAN 19, 2001) 1 01/19/2001 10:27 Infection Control SNOW,C Visit: 01/26/1999 2 12/30/2000 16:00 + Discharge Summary STRANDER,R Adm: 12/25/2000 Dis: 12/30/2000 3 11/01/2000 14:00 Discharge Summary STRANDER,R Adm: 04/19/2000 Dis: 11/01/2000 4 04/24/2000 00:00 Discharge Summary STRANDER,R Choose one or more documents: (1-4):1 Pick Date Range

Example continued Browse Document Jan 19, 2001 10:33:50 Page: 1 of 1◄ Infection Control ZTEST,M 123-45-6789 AUDIOLOGY AND SPE Visit Date: 01/26/1999 17:50 ◄ DATE OF NOTE: JAN 19,2001@10:27:57 ENTRY DATE: JAN 19,2001@10:27:58 AUTHOR: BARCODE, BILLY EXP COSIGNER: URGENCY: STATUS: UNSIGNED Pt is very sick... + Next Screen - Prev Screen ?? More actions Find On Chart Reassign Print Amend Send Back Edit Delete Quit Verify/Unverify Select Action: Quit// R Reassign Are you sure you want to REASSIGN this Infection Control? NO// Y

Retracted Documents Retracted is a status that occurs when the original document has been deleted or reassigned Business rules are set up to identify who may view retracted documents If you reassign a document to a different patient, TIU will retract the original If you delete a document, the original will be retracted

Example of Retracted Document in TIU 1 10/12/2004 14:09 SURGERY PRE-ANESTHESIA (RETRACTED) ZIPPER,K Visit: 10/12/2004 2 10/05/2004 15:07 MEDICINE-STUDENT NOTE (RETRACTED) DERSTINE,C

TIU Document Header for Retracted Document DATE OF NOTE: OCT 05, 2004@15:07 ENTRY DATE: OCT 05, 2004@15:07:47 AUTHOR: DERSTINE,CHRISTINA EXP COSIGNER: ZIPPER,KIMBERLY RN URGENCY: STATUS: RETRACTED

Locking and Unlocking Visits Parameters for locking The default parameter for locking a visit, in the EHR, is set at three days.  The recommendation for the visit lock should be set to no greater than 7 days.

Unlocking a Locked Visit The Chief, MIS can unlock visits when data needs to be added or changed. In RPMS at the “Select IHS Kernel Option” prompt, select EHR  ENC  OVR Enter the date and time of visit you want to unlock Relock the visit when finished

Unlock a Locked Visit

Relocking the Visit Same Menu option to Unlock a Locked Visit In RPMS at the “Select IHS Kernel Option prompt, select EHR  ENC  OVR

Interdisciplinary Notes Interdisciplinary notes consist of individual progress notes Each individual note is attached to a parent note Each interdisciplinary note is displayed as a single entity

Interdisciplinary Notes Each part of the interdisciplinary note has a single author Interdisciplinary notes are not addendums Each entity of an interdisciplinary note can have a different title-this differentiates them from addendums You can add an addendum to an interdisciplinary note

Interdisciplinary Notes Interdisciplinary notes can have a template assigned to them, whereas an addendum cannot have the template populate automatically You can assign business rules to each title Parent/child notes

Interdisciplinary Notes Well Child Care could be set up as interdisciplinary notes The initial visit is the parent note Each well child visit is added as a child note They are kept in one folder Visits other than well child are not added to the well child parent note

Interdisciplinary Notes Another example, using multidisciplines: CHF clinic notes LPN begins note with V/S and initial note Physician adds first child note RN sees patient before they go home to review medications and writes additional child note

Disadvantages of Interdisciplinary Notes The author of the parent note is the author displayed first Author of the parent note needs to do the author’s note first so others may be attached Set up is more involved than regular progress notes

Set-up of Interdisciplinary Notes Parent note Set up ID parent document class and ID child document class Some facilities name all ID notes starting with ID so they are easier to find Set up business rules Parent note must have business rule to allow attachments

Example of Business Rules for ID Parent Document Class

Example of Business Rules for ID Team Document Class

Set up of ID notes, cont. Add note titles to appropriate document class Attach templates to document titles if desired Training

Writing Interdisciplinary Notes Parent Note Select “New Note” Select parent title Complete template, if available Sign note

Writing Interdisciplinary Notes Child Note Open parent note Either right click or select “Action” Select “Add New Entry to Interdisciplinary Note” Select child note title Complete note and sign

Completed Notes Appear in Folder

Attach Completed Child Note to a Parent Note If the child note is completed prior to the parent note, it can be attached at a later time by clicking and dragging it to the parent note. The following message will display:

Display of ID Notes EHR displays all notes in the ID Note in date order If a child note is selected: it displays first, then all the notes in the ID Note display in date order. In all other respects, the format of the display is the same as a regular note. The display of unsigned notes depends upon the business rules in effect at your site. These rules may allow you to view the unsigned child notes of other providers in the context of an Interdisciplinary Note.

Late Entry When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the health record. The new entry should be identified as “late entry.” The late entry must be noted with the actual date the event occurred vs. the date of documentation. Notation as to the reason for the delay is also suggested. In the EHR, the date of entry identifies when the documentation actually occurred. Physicians and other healthcare providers must monitor and take appropriate action on their computerized prompts for signature.

Questions & Discussion