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changing transcription - R

Posted: Jan 18, 2010

I recently discovered that another employee has been making changes to transcription that carries my initials along side the doctor's initials, which indicates me as the transcriptionist.

I feel that this is not only inappropriate, but possibly also illegal.

Is it illegal for someone to change transcription done by someone else without their knowledge and/or permission? Can I be held responsible for her changes within my reports?

I do have copies of my original transcriptions in the form of computer files. However, she has filed her changes in the patient's charts with these notes identified by the name/initials of the dictating doctor and my initials as the transcriptionist.

changing initials - old mt

[ In Reply To ..]
I would take it up with the doctor/company you work for. Is it possible hers are the same? One of you just needs to change yours. If she is blatantly doing this I would change yours, tell them why and see what happens.

changing initials - R

[ In Reply To ..]
No, her initials are not the same as mine, and she is NOT even a transcriptionist. She receives the completed transcription and is responsible for having it signed by the dotor and filing it in the charts. If the doctor needs changes, it is office policy that I be notifed so that I can make the changes. However, she has apparently been making changes on her own, which means that the notes that are filed in the chart do not match the computer files and that my initials are attached to notes that I have not even seen. I have asked her not to change my transcription, but she insists that she can do so as long as they have not yet been placed in the chart. I feel that she has no business changing transcription and I am hopeful that someone can point to a legal reference to proove my point. Thanks for your help!

I dont know the legalities of it - but (sm)

[ In Reply To ..]

I would not let another minute go by without taking this up with the Office Manager, or whomever runs that office. If there is no one, I would speak to the doctor himself. Don't waste any more time on the person who is doing it, that didn't work for you. Go over her head.

I would not do any more transcription until this practice was stopped.

Believe me, the blame will fall on you for any discrepancies or incorrect notes. Having the original in your computer files is not going to back you up. They can say you changed YOUR notes and the note in the chart is the correct/original note.

I would be boiling over this too.

changing initials - old mt

[ In Reply To ..]
definitely tell the hirer ups. That is just not right. I would start looking for another job.

paper or electronic record? draft or authenticated version? sm - flybye

[ In Reply To ..]
This is a serious issue; from your post it's impossible to tell what situation your have; there are MANY variables affecting legality such as current policies in place, access rights, version, authentication, etc. Are you an employee or contractor? on-site or remote?

You said, "She receives the completed transcription and is responsible for having it signed by the dotor and filing it in the charts."

Once the doctor SIGNS the record, it is AUTHENTICATED and CANNOT BE CHANGED.

You said, "If the doctor needs changes, it is office policy that I be notifed so that I can make the changes. However, she has apparently been making changes on her own, which means that the notes that are filed in the chart do not match the computer files and that my initials are attached to notes that I have not even seen."

If the practice has a written security policy that indicates changes are ONLY to be made by the original MT and that the office MUST notify MT to make those changes, then she is in violation of that security policy.

You said, "I have asked her not to change my transcription, but she insists that she can do so as long as they have not yet been placed in the chart." Changes can be made to a draft, but an AUDIT TRAIL must be in place either on paper or electronically, documenting ANYONE who has access to the record...with a time stamp indicating any change made to the record.

This is a security and legal issue; I invite you to research

HIPAA Security Rules and AHIMA Legal Documentation guidelines

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028509.hcsp?dDocName=bok1_028509

Here's a quote: "It is acceptable for a draft of a dictated and transcribed note or report to be changed before authentication unless there is a reason to believe the changes are suspect and would not reflect actual events or actions. Facility policy should define the acceptable period of time allowed for a document to remain in draft form before the author reviews and approves it (e.g., 24 to 72 hours). Once a document is no longer considered a draft or has been authenticated, any changes or alterations should be made following the procedures for a late entry or amendment. The original document must be maintained along with the new revised document."

paper records - R

[ In Reply To ..]
Thank you for your input. I read the article you referenced and believe it will be helpful.
I am an employee of a multi-office practice. I work off-site and as the sole transcriptionist for the practice. Dictation is transcribed and transmitted electronically to the appropriate office, where it is printed, signed and added to the appropriate patient charts as a paper record.
Apparently these questionable changes are being made before the documents are signed and placed in the charts - - but without an audit trail.
My concern it that my initials identify the items as my transcription, and I do not wish to be held responsible for what this other employee is doing.
As of today, I plan to send all documents in a read-only format to hopefully prevent alteration of my original file, although I will still have no control over what she does with the paper copies.
I will present the AHIMA article you suggested to my practice manager and suggest she put the office policy regarding altering transcription in writing. Thanks again for your help and any other thoughts you may have regarding this.

another backup of the original could be done - see inside

[ In Reply To ..]
by using print screen and pasting the screen shot, including date and time from your toolbar, into a Word document for your own backup. No one can claim these have been altered in any way by anyone.

Good luck! Let us know what happens.

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