CORRECTION OF PATIENT CHARTS

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

  • Please let me know the correct way to make a correction to a medical record and where I can find the information in writing.

Sign In or Register to comment.