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Wiki changes to anesthesia record
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dwaldman
True Blue
Below is from HCPro which I thought was relevant to your question> I also found a link from AIHMA that I thought was good reference.
http://www.hcpro.com/HIM-251599-5707/QA-Policies-for-late-entry-documentation.html
Q&A: Policies for late entry documentation
CDI Strategies, May 27, 2010
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Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary history and physical? Can you help me with citations for this, as well?
A:The American Health Information Management Association published practice guidelines that address late entries as follows:
“Any clinical provider documenting within the health record may need to enter a late entry. The organization should clearly define how this process occurs within their system. Tracking and trending within the electronic record will be dependent on the system; the organization should clearly understand this process.
“In addition, specific policies and procedures should guide clinical care providers on how to correctly make a late entry within the health record. The author should document within the entry that it is a late entry.
“Typically late entries apply to direct documentation only; for example, physician orders, progress notes or nursing assessments. Dictated reports such as history and physicals, although dictated outside of organizational time frames, would not be considered a late entry.
“Note: Some systems may not have late entry functionality. The late entry is shown as an addendum.�
The following is an example of one institution's policy regarding late entries:
When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:
Identify the new entry as a “late entry.�
Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.
The entry must be signed.
Identify or refer to the date and circumstance for which the late entry or addendum is written.
When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.
An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.
Document the date and time on which the addendum was made.
Write “addendum� and state the reason for creating the addendum, referring back to the original entry.
When writing an addendum, complete it as soon as possible after the original note.
Editor's Note: This question was answered by Fran Jurcak, RN, MSN, CCDS, a manager with Wellspring + Stockamp, a division of Huron Healthcare in Chicago. Contact her at fjurcak@huronconsultinggroup.com.
_____________________________________________________________
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028509.hcsp?dDocName=bok1_028509
Excert below is from AIHMA's Update: Maintaining a Legally Sound Health Record—Paper and Electronic
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.
• Identify the new entry as “late entry.â€�
• Enter the current date and time. Do not try to give the appearance that the entry was made on a previous date or time.
• Identify or refer to the date and incident for which the late entry is written.
• If the late entry is used to document an omission, validate the source of additional information as much as possible (e.g., where you obtained the information to write the late entry).
• When using late entries, document as soon as possible. There is no time limit to writing a late entry; however, the more time that passes, the less reliable the entry becomes.
Amendments
An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. When making an addendum:
• Document the current date and time.
• Write “addendumâ€� and state the reason for the addendum referring back to the original entry.
• Identify any sources of information used to support the addendum.
• When writing an addendum, complete it as soon after the original note as possible.
• In an electronic system it is recommended that organizations have a link to the original entry or a symbol by the original entry to indicate the amendment. ASTM and HL7 have standards related to amendments.
Healthcare organizations should have policies to address how a patient or his or her representative can enter amendments into the record. The HIPAA privacy rule requires specific procedures and time frames be followed for processing an amendment. A separate entry (progress note, form, typed letter) can be used for patient amendment documentation. The amendment should refer back to the information questioned, date, and time. The amendment should document the information believed to be inaccurate and the information the patient or legal representative believes to be correct. The entry in question should be flagged to indicate a related amendment or correction (in both a paper and electronic system). At no time should the documentation in question be removed from the chart or obliterated in any way. The patient cannot require that the records be removed or deleted.
http://www.hcpro.com/HIM-251599-5707/QA-Policies-for-late-entry-documentation.html
Q&A: Policies for late entry documentation
CDI Strategies, May 27, 2010
Want to receive articles like this one in your inbox?
Subscribe to CDI Strategies!
Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary history and physical? Can you help me with citations for this, as well?
A:The American Health Information Management Association published practice guidelines that address late entries as follows:
“Any clinical provider documenting within the health record may need to enter a late entry. The organization should clearly define how this process occurs within their system. Tracking and trending within the electronic record will be dependent on the system; the organization should clearly understand this process.
“In addition, specific policies and procedures should guide clinical care providers on how to correctly make a late entry within the health record. The author should document within the entry that it is a late entry.
“Typically late entries apply to direct documentation only; for example, physician orders, progress notes or nursing assessments. Dictated reports such as history and physicals, although dictated outside of organizational time frames, would not be considered a late entry.
“Note: Some systems may not have late entry functionality. The late entry is shown as an addendum.�
The following is an example of one institution's policy regarding late entries:
When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:
Identify the new entry as a “late entry.�Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time.The entry must be signed.Identify or refer to the date and circumstance for which the late entry or addendum is written.When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.Document the date and time on which the addendum was made.Write “addendum� and state the reason for creating the addendum, referring back to the original entry.When writing an addendum, complete it as soon as possible after the original note.Editor's Note: This question was answered by Fran Jurcak, RN, MSN, CCDS, a manager with Wellspring + Stockamp, a division of Huron Healthcare in Chicago. Contact her at fjurcak@huronconsultinggroup.com.
_____________________________________________________________
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028509.hcsp?dDocName=bok1_028509
Excert below is from AIHMA's Update: Maintaining a Legally Sound Health Record—Paper and Electronic
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.
• Identify the new entry as “late entry.â€�
• Enter the current date and time. Do not try to give the appearance that the entry was made on a previous date or time.
• Identify or refer to the date and incident for which the late entry is written.
• If the late entry is used to document an omission, validate the source of additional information as much as possible (e.g., where you obtained the information to write the late entry).
• When using late entries, document as soon as possible. There is no time limit to writing a late entry; however, the more time that passes, the less reliable the entry becomes.
Amendments
An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. When making an addendum:
• Document the current date and time.
• Write “addendumâ€� and state the reason for the addendum referring back to the original entry.
• Identify any sources of information used to support the addendum.
• When writing an addendum, complete it as soon after the original note as possible.
• In an electronic system it is recommended that organizations have a link to the original entry or a symbol by the original entry to indicate the amendment. ASTM and HL7 have standards related to amendments.
Healthcare organizations should have policies to address how a patient or his or her representative can enter amendments into the record. The HIPAA privacy rule requires specific procedures and time frames be followed for processing an amendment. A separate entry (progress note, form, typed letter) can be used for patient amendment documentation. The amendment should refer back to the information questioned, date, and time. The amendment should document the information believed to be inaccurate and the information the patient or legal representative believes to be correct. The entry in question should be flagged to indicate a related amendment or correction (in both a paper and electronic system). At no time should the documentation in question be removed from the chart or obliterated in any way. The patient cannot require that the records be removed or deleted.