Presentation on theme: "Text Integration Utility (TIU) - Correcting Documents Entered in Error"— Presentation transcript:
1Text Integration Utility (TIU) - Correcting Documents Entered in Error EHR for HIM
2Deleting 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 recordYou receive the call to delete the note and the attached addendumThis can be done in either TIU or EHR
3Deleting 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
4To Delete the Document in EHR Open the note in EHRRight click or select “Action” menuSelect “Delete progress note”You will see the following:
5In this example, I chose Administrative Action because I am deleting the note due to the author entering it in errorSelect “Yes” on the confirm deletion screenThe following message will display:
6Correct/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.
7Correct/Amend continued While viewing a note in TIU, select the action “Amend”You will be prompted to enter your signature codeThe TIU Editor will allow you to make editsThe original note will be retracted and the new note will have a status of Amended
8Example of Amended Note DATE OF NOTE: JUL 13, ENTRY DATE: OCT 19,AUTHOR: ZIPPER,KIMBERLY RN EXP COSIGNER:URGENCY: STATUS: AMENDEDSUBJECT: testztest/es/ KIMBERLY ZIPPERRNSigned: 07/13/ :4210/19/ :13 AMENDMENT FILED:
9Reassigning Documents The reassign action reassigns a note to a different patient, admission, or visitThe reassign action may also be used to promote an Addendum as an Original, swap the Addendum and the Original
10Who Can Reassign Documents? Reassigning completed documents is usually restricted to a specific User Class, for example, Chief, MISThis includes notes that are awaiting co-signatureUnsigned notes may be reassigned by the Author/Dictator
11The 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.
12Unsigned 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 Document2 Multiple Patient Documents3 Print Document Menu ...4 Search for Selected Documents5 Statistical Reports ...6 Unsigned/Uncosigned ReportSelect Text Integration Utilities (MIS Manager) Option: 1 IndividualPatient DocumentSelect PATIENT NAME: car1 TEST, PATIENT YES NON-SERVICE CONNECTED THIS IS A TEST2 ZTEST,MALE NO NON-SERVICE CONNECTEDCHOOSE 1-4: 2 ZTEST,MALE NO NON-SERVICE CONNECTED THIS IS A TEST(1 note ) C: 03/16/99 10:20Available documents: 11/23/1998 thru 01/19/2001 (19)
13Example continuedPlease 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,CVisit: 01/26/19992 12/30/ :00 + Discharge Summary STRANDER,RAdm: 12/25/2000 Dis: 12/30/20003 11/01/ :00 Discharge Summary STRANDER,RAdm: 04/19/2000 Dis: 11/01/20004 04/24/ :00 Discharge Summary STRANDER,RChoose one or more documents: (1-4):1PickDateRange
14Example continued Browse Document Jan 19, 2001 10:33:50 Page: 1 of 1◄ Infection ControlZTEST,M AUDIOLOGY AND SPE Visit Date: 01/26/199917:50◄DATE OF NOTE: JAN ENTRY DATE: JANAUTHOR: BARCODE, BILLY EXP COSIGNER:URGENCY: STATUS: UNSIGNEDPt is very sick...+ Next Screen - Prev Screen ?? More actionsFind On Chart ReassignPrint Amend Send BackEdit Delete QuitVerify/UnverifySelect Action: Quit// R ReassignAre you sure you want to REASSIGN this Infection Control? NO// Y
15Retracted DocumentsRetracted is a status that occurs when the original document has been deleted or reassignedBusiness rules are set up to identify who may view retracted documentsIf you reassign a document to a different patient, TIU will retract the originalIf you delete a document, the original will be retracted
16Example 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
17TIU Document Header for Retracted Document DATE OF NOTE: OCT 05, ENTRY DATE: OCT 05,AUTHOR: DERSTINE,CHRISTINA EXP COSIGNER: ZIPPER,KIMBERLY RNURGENCY: STATUS: RETRACTED
18Locking and Unlocking Visits Parameters for lockingThe 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.
19Unlocking 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 OVREnter the date and time of visit you want to unlockRelock the visit when finished
21Relocking the Visit Same Menu option to Unlock a Locked Visit In RPMS at the “Select IHS Kernel Option prompt, select EHR ENC OVR
22Interdisciplinary Notes Interdisciplinary notes consist of individual progress notesEach individual note is attached to a parent noteEach interdisciplinary note is displayed as a single entity
23Interdisciplinary Notes Each part of the interdisciplinary note has a single authorInterdisciplinary notes are not addendumsEach entity of an interdisciplinary note can have a different title-this differentiates them from addendumsYou can add an addendum to an interdisciplinary note
24Interdisciplinary Notes Interdisciplinary notes can have a template assigned to them, whereas an addendum cannot have the template populate automaticallyYou can assign business rules to each titleParent/child notes
25Interdisciplinary Notes Well Child Care could be set up as interdisciplinary notesThe initial visit is the parent noteEach well child visit is added as a child noteThey are kept in one folderVisits other than well child are not added to the well child parent note
26Interdisciplinary Notes Another example, using multidisciplines:CHF clinic notesLPN begins note with V/S and initial notePhysician adds first child noteRN sees patient before they go home to review medications and writes additional child note
27Disadvantages of Interdisciplinary Notes The author of the parent note is the author displayed firstAuthor of the parent note needs to do the author’s note first so others may be attachedSet up is more involved than regular progress notes
28Set-up of Interdisciplinary Notes Parent noteSet up ID parent document class and ID child document classSome facilities name all ID notes starting with ID so they are easier to findSet up business rulesParent note must have business rule to allow attachments
29Example of Business Rules for ID Parent Document Class
30Example of Business Rules for ID Team Document Class
31Set up of ID notes, cont.Add note titles to appropriate document classAttach templates to document titles if desiredTraining
35Attach 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:
36Display of ID NotesEHR displays all notes in the ID Note in date orderIf 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.
37Late EntryWhen 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.