Question Post-Signature Addendums in EHRs/EMRs?

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carlystur

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While this isn't my responsibility as a coder, I am curious about this in general.

We are using eClinicalWorks for our EMR and whenever our providers make any changes after their first signature, the change gets made, but there doesn't appear to be any strike-throughs or provider initials next to the changes that were made to the notes. I believe that strike-through and provider initials is the proper way to handle changes to documentation after signing for the first time, but I am unaware if this is an option in ECW, or in any EMR. My guess is that other EMRs have this option and it gets used properly. I could even guess that ECW does have this option and it just doesn't get used by our providers, either because they don't know about it or they just don't want to use it.

Can someone tell me regarding either ECW or other EMRs regarding if the proper procedure for post-signature addendums are shown on the documentation itself using the EMRs?
 
In any EMR, when there is an addendum, the change may be sort of "behind the scenes". The EMR is required to track who/what/when the change was made, but often the initial view or printed view is a "prettied-up version." I know our EMR displays what the current signed version is, and you have to click an extra button or 2 to see the original and/or changes. A previous EMR I used would do something similar. In that, you had to select the voided version to see the original and changes.
I've never used ECW, but I imagine there is something similar. You don't want to make what is now an incorrect document TOO visible and easy to misunderstand. Perhaps another ECW user can tell you the steps, or you can reach out to ECW directly.
 
Our EMR also replaces the original note with the amended note after a provider makes a correction. All prior versions still exist and are viewable in the record and have "(replaced)" after the document name and the text in the note listing is a different color. Once a note is signed, our providers can only modify a copy of the original note. While it doesn't show the actual information that is being replaced, like a strike-out would in a paper chart, a side-by-side comparison of both records can be done and the system logs retain the activity if needed.

The software also has a user setting that allows us to hide those replaced notes, which seems similar to what csperoni described.
 
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