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Modify or delete errant information

I have had rare occasion where information was added to the wrong chart, either a diagnosis, prescription, or an entire note. Now it remains on the patient's record forever. For legal reasons, I know we cannot alter a record, but it would be nice if that errant information could be moved out of the existing information so that errors do not occur in reproducing this information. For example, if you print a med list or print a chart, that information goes with it and an addendum at the bottom my not be enough to prevent a consultant or other provider from realizing it is not valid information. Perhaps the there could be some marker left in the record that information was altered, with a link to the deleted information (stored somewhere else) and an explanation as to why it was removed.

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Dr Douglas Haas shared this idea  ·   ·  Admin →
Acknowledged  ·  Matthew Douglass responded  · 

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6 comments

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  • Edward Taubman commented  · 

    I think we should have a "time out" period of say 30 minutes in which we could unsign something or remove something put in error;

  • Dr Samuel Sharmat commented  · 

    As Dr. Muncy-Pietrzak recommended: please allow an "entered in error" or "strikethrough" or "deleted information" "- click to view" feature for signed notes. The summary tab shows enough info to show the encounter but not enough to show the addenda - so wrong conclusions can be made. Please add this functionality.

  • J Steve Mayo commented  · 

    In accordance with EMR tracking, an item (note/message/lab) would be marked as "erroneous", and never shared as part of the chart again. Then it could be only pulled as legal request etc... subpoena.

  • Anonymous commented  · 

    OMG yes please... you cannot remove a note that is in the wrong chart!

  • Lisa Muncy-Pietrzak, MD commented  · 

    In a paper record when one found a result in the wrong chart, the piece of paper would be refiled into the correct chart. One did not "alter" the first record as the information was not relevant in the first place. It is true that having erroneous information in a chart is problematic as one can make clinical decisions based on the information--then additional documentation is required, etc. The inability to remove erroneous information from the end users' view is available in the electronic realm. It can stay discoverable, but should not be left to be viewed and potentially acted upon. At the very least, add the ability to draw lines and initial any changes--the way we did in a paper chart.

  • Paul Sorell commented  · 

    Consistent with this idea/request: We should be able to DELETE mistakenly-selected pharmacies (to which NO eRx's have been transmitted) from a patient's record. There is no legal trail here...Just an outright mistake...and now that incorrect pharmacy remains "wrongly" active in the patient's record.

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