CORRECTION OF PATIENTS' RECORDS

ilagtapon@kabafusion.comilagtapon@kabafusion.com
in Oasis General
Hello everyone. Can you share how do you correct charts if there are missing orders or no care coordination documented? We send email to our nurses and they correct it themselves. However I've heard that our software will only allow nurses to do corrections until the end of the episode. Sometimes the chart audit does not really happen in real time and have some delay due to other tasks and responsibilities that need to get done as well. Someone in our office is asking the QA/PI to enter the missing order or the missing care coordination note in the patient's chart in behalf of the nurse if the episode has already ended. What do you think of this?

Comments

  • ahcoder911@hotmail.comahcoder911@hotmail.com
    edited May 2017
    I think you need to have a conversation with your software provider.
  • ilagtapon@kabafusion.comilagtapon@kabafusion.com
    Thank you for your response. Is that ok and acceptable if a clinician from the office will enter an MD order in behalf of the nurse if the episode has ended and the nurse cant access the patient record any longer with the phrase " As per Nurse XX-- MD order to do XXXX" and the signature that in the order is the clinician that enter the order.
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