Good Morning,
We have concerns regarding how edits to documentation display in the EMR and were wondering if other sites share our concerns. Edited clinical documentation appears in the EMR in a somewhat misleading manner. In the paper world, when clinical data was edited, the user would cross out the incorrect data and initial the change. A new entry would be entered with the current date and time and the entry would state what the edit contained. Currently in the EMR when a change is made to the data, the new data replaces the old data in the assessment and retains the data and time of the original document. There is no indication that a change has been made within the EMR. So clinicians, who are referencing the EMR and have made certain clinical decisions based upon the information found there, may find it hard to substantiate those decisions if the data has changed. The system also allows a clinician to edit the documentation previously entered by another clinician. This edit is attributed to the original documenter, without a reference to the second documenter. The audit trails do give the detail of the changes but the audits are within the individual modules, with more than one module it is difficult to determine the entry point to search out the edits made. We would like to see the EMR give a true picture of the documentation and changes made to the documentation and would like to know if you have addressed issues similar with Meditech. Thank you, Barb Homich Clinical Apps. Manager Berkshire Health Systems BHS CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please notify Berkshire Health Systems immediately by e-mail at [EMAIL PROTECTED] and destroy all copies of this communication and any attachments.
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