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

2. 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

3. 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

4. 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:

5. 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:

6. 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.

7. 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

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

9. 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

10. 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

11. 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.

12. 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 YES NON-SERVICE CONNECTED THIS IS A TEST
2 ZTEST,MALE NO NON-SERVICE CONNECTED
CHOOSE 1-4: 2 ZTEST,MALE 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)

13. 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/ :27 Infection Control SNOW,C
Visit: 01/26/1999
2 12/30/ :00 + Discharge Summary STRANDER,R
Adm: 12/25/2000 Dis: 12/30/2000
3 11/01/ :00 Discharge Summary STRANDER,R
Adm: 04/19/2000 Dis: 11/01/2000
4 04/24/ :00 Discharge Summary STRANDER,R
Choose one or more documents: (1-4):1
Pick
Date
Range

14. Example continued Browse Document Jan 19, 2001 10:33:50 Page: 1 of 1◄
Infection Control
ZTEST,M AUDIOLOGY AND SPE Visit Date: 01/26/1999
17:50 ◄
DATE OF NOTE: JAN ENTRY DATE: JAN
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

15. 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

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

17. TIU Document Header for Retracted Document
DATE OF NOTE: OCT 05, ENTRY DATE: OCT 05,
AUTHOR: DERSTINE,CHRISTINA EXP COSIGNER: ZIPPER,KIMBERLY RN
URGENCY: STATUS: RETRACTED

18. 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.

19. 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

20. Unlock a Locked Visit

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Example of Business Rules for ID Parent Document Class

30. Example of Business Rules for ID Team Document Class

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

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

33. 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

34. Completed Notes Appear in Folder

35. 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:

36. 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.

37. 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.

39. Questions & Discussion