Administrative Edits to Medical Record

Do any of you in HIM practice placing administrative edits into transcribed documents that have already been signed off by the clinical provider. Administrative addendums might include a note about the correct date of service or account number, which cannot be corrected after the provider signs the report.

I'm "old school" that HIM does not document in the medical record, but wasn't sure if that practice had changed over the years.

Marianne Dailey, RHIT, CHP. CPHQ
Director HIM & Privacy Officer
Central Peninsula Hospital
Soldotna, Alaska 99669
(907) 714-4563
mdailey@cpgh.org

Comments

  • edited May 2016
    We do not document in the medical record.



    Suzanne LeMaire, RHIT

    HIMS Leader

    Scheurer Hospital

    170 North Caseville Road

    Pigeon, MI 48755-9781

    phone: 989.453-5205

    fax: 989-453-4455

    email: lemaires@scheurer.org







  • edited May 2016
    Any corrections to the document to correct the account number, correct the date of service, or corrections from the physician are done in transcription. The electronic document goes back to the provider for a signature. Any revisions made to the document are noted at the beginning of the document. This special notation was put in place to make sure the corrected report was correctly displayed in our web portal.

    Sheila Schultz
    Director of HIM
    Wheeling Hospital
    One Medical Park
    Wheeling WV 26003
    304-243-3695
    Fax 304-243-8599
    ssschultz@wheelinghospital.org


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