AHIMA has published a new toolkit, “Amendments in the Electronic Health Record,” that provides guidance on how to maintain the integrity and accuracy of an electronic health record system (EHR) when staff use the system’s amendment functionality. Amendments include addendums, corrections, and deletions to EHR data.
According to the toolkit, “Organizations must have established policies and procedures to guide the provider when changes need to be made and how to make these changes within the health record.” If a facility’s staff members are using the amendment function, HIM professionals must make sure that the set policies and procedures work to maintain the integrity and accuracy of the record.
Guiding principles set forth in the toolkit include:
- Addendum Practice Guidelines: Organizations should clearly define for providers that once a document has a final sign-off, the only way to correct or revise the documentation is to provide an addendum. The organization should have a specific policy and procedure addressing how addendums are made in the health record.
- Correction Practice Guidelines: Organizations should have a clear policy and procedure covering its system’s ability to issue documentation corrections. The policy and procedure should cover issuing corrections to a signed document, as well as issuing corrections to a document before it is signed.
- Late Entries Practice Guidelines: Any provider documenting within the health record may need to add a late entry. The organization should clearly define how this process occurs within its system, including the time frame that late entries may be inserted. Tracking and trending within the electronic record will be dependent on the system; organization staff should clearly understand this process.
- Retractions Practice Guidelines: Depending on the organization’s electronic system, locked reports may require specific interventions to retract information. For example, in some systems only HIM department personnel can unlock a report, which ensures that an audit trail of altered information is recorded. Organizations should develop guidelines for making these types of entries.
- Deletion Practice Guidelines: It is recommended that system functionality never allow for the total elimination of information. If the organization allows information to be deleted, it needs to follow clear policies and procedures that ensure the integrity of the health record, and staff should monitor and audit this functionality frequently.
- Re-sequencing or Reassignment: Identifying and monitoring date of service errors is crucial to effectively managing corrections in the EHR. Organizations should have a process for reporting errors found within the EHR.
Further detailed guidelines and additional processes that put best practices in motion are included in the full toolkit, accessible via the AHIMA Body of Knowledge. The tool kit is free to AHIMA members.