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Can doctors edit?-sm - poorhouse

Posted: Dec 20, 2013

Just wondering...when the documents are imported into the client's system, can their doctors edit them if they find an error before they sign off on them? When I worked in-house, the doctors could either edit the report or re-dictate whatever we had blanked. I'm just guessing that the reports go to a queue for the doctors to "read" and then sign since, legally, they are ultimately responsible for what they dictate. Just wondering if anyone knew. TIA. I had a doctor the other day say an initial troponin was "point one" very clearly that I even re-listened to. Later in the report, they stated the initial troponin was "point oh one." I typed it verbatim. One time a doctor said the pt had a 365-pack-year history of smoking. I questioned that and the doctor wanted it left that way. Oooookay, you get paid the big bucks! Ugh. If it's clearly stated, I don't question anything.

Can doctors edit? - Yeah, when

[ In Reply To ..]
pigs fly. Do you really think they are going to take the time, what with the 15 minute window they allow for each patient. I have had doctors sometimes spell things as I think it was misspelled in the previous report and they caught it, but not a regular basis. I am not under such rigid constrictions as so many MTs are with this QA business; so I can improvise and correct as I go. I too have sent a note stating, something like you did about the smoking, but if the doctor wants it that way, then so be it. WHATEVER! By the way on GMA this morning, that was voted the most hated word! Kind of says it all sometimes though.

they dictate their edits - anon

[ In Reply To ..]
Sometimes I'll get a report that the doctor does an addendum on and it will be something to the effect that he is filling in the blanks or mistakes from a previous dictation.

I think there are some doctors that are dilligent in looking at their reports and wanting things to be right. I think there are others that don't care. But that's only my opinion and I have no statistics to back that up.

Exactly! - poorhouse

[ In Reply To ..]
When I was in-house, some of the docs would make edits or fill in blanks on reports, capitalization errors, formatting errors, the report just looked like trash but HEY it was complete! Yeah, whatever sums it up perfectly. :D

Yes, they can and do edit before signing - sm

[ In Reply To ..]
In a paper record, they get a printed report. They can write their changes on it.

In an EHR, everything is electronic,but of course they can edit. In fact, they MUST be able to edit before signing the report. Once they sign it, it is locked, but they can make changes by adding an addendum.

In house we made changes to signed reports without - having to do an addendum, but

[ In Reply To ..]
An addendum is one way of doing it and is the preferred method if the report is more thsn 30 days old.

Otherwise, you can edit a signed report, but once you do, the doc's signature is no longer there and they have to re-sign it.

In an EHR??? - Should not be possible

[ In Reply To ..]
Was this in an actual EHR?

An EHR should not allow changes to be made to a signed report. It shouldn't allow it to begin with, but should not allow it to be edited and re-signed, either. Doing so destroys the integrity of the record as a legal document.

Yep, in an EHR you most certainly can and SHOULD - be able to edit signed or unsigned.

[ In Reply To ..]
Not if you work for an MTSO, but the hospitals, clinics and physician's have the capability to edit documents whether they are signed or not.

It's all tracked... - poorhouse

[ In Reply To ..]
One of the reasons docs don't like it...it tracks when they look at a document, how long they look at it, when/if they make any corrections. It tracks it much easier than paper, that's for sure. In the system they used when I was in-house, the docs had to e-sign documents with ONE click of a mouse; if they left their cursor in the same place on the screen, once they clicked to sign a document, the next one would load up and they'd click again. If a report was incomplete, they had to address it, either by filling in blank/s or re-dictating.

Yes, we had a couple that would - send reports back instead of

[ In Reply To ..]
Just doing it themselves. When they go in to sign the report they can make any changes they want.

When I worked in-house we had quite few corrections we made for mistakes made by the service doing our over-flow, but they were mainly for our difficult docs. Eventually they made it so those came in on a hold que so we could edit them first to stop the doctors from complaining.

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