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Re: Legal Requirements to Sign off an encounter in EMR World

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I would think in an EMR all the timing of your enteries can be traced. I was taught NEVER alter your charts in any way. If there is a law suit, you can be charged with fraud for which there is no limit on the judgement. Where as strictly medical errors have a limit, at least here in CA. The fraud judgements are punitive and designed to " hurt " you personally. Write what you write, give yourself enough time to finish your chart between pts. Do an Addendum if you need too. That can be just " style of charting " . I tend to chart complicated cases at the end of my day because too stressful and rushed between pts to complete charts with clarity. Since I am going to be a cash only practice, I am going to CMS1500 form and send it for the pt at the end of the day.

I would like to get educated from you all as if there are any legalrequirements (time limit) to sign off a chart (Encounter) in any EMRso that it cannot be modified.I know paper charts can be changed anytime to correct any mistakes or

errors in documentation, but in the EMR world, once you sign it,that's the final word. I know you can add addendums to any particulardate encounter.The EMR we use (Amazing Charts) does not allow you to proceed further

to create a super bill until you sign of an encounter. I have aworkflow issue with that restriction, but that is another issue. Iknow other EMRs people are using and few if not a lot of physicians donot sign off their encounters even until it is paid, even for months.

This way they can make adjustments to their documentation ifrequired, and even add or omit some facts for their benefit in a legalsituation.Please share your legal expertise or knowledge.Thanks in advance!

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Yes, in eMDs you can unsign off a note for about 24-48 hours and edit it. After

that you can add an addendum, which show up as an addendum, but you can unsign

off the note. This is for obvious legal reasons. It is audited by person. You

can bill anytime a provider says the note is billable. If the charges change you

can amend the bill and resend it.

I believe the legal standard for signing off a note is a year, whether it is

paper or electronic.

________________________________

From: on behalf of Pratt

Sent: Mon 6/9/2008 4:29 PM

To:

Subject: RE: Legal Requirements to Sign off an encounter

in EMR World

We use e-MDs. Bills can go out if not signed off, as long as the provider

indicates that it's ready to bill. Charts in e-MDs can also be " unsigned " and

then signed again so that you can add to or delete from your original note. As

far as I know, all of the changes are recorded in the audit trail.

Recent information that came to me from an insurer indicated that charts should

be signed off no later than one year from DOS.

We have one provider (my husband) who signs all notes before he leaves for the

day. The other provider has some notes that are sitting unsigned from a month

ago. They don't go to his biller until he's signed the chart. Otherwise the

charts would never get signed.

Pratt

Office Manager

Oak Tree Internal Medicine P.C.

________________________________

From:

[mailto: ] On Behalf Of imdadb

Sent: Sunday, June 08, 2008 2:48 PM

To:

Subject: Legal Requirements to Sign off an encounter in

EMR World

I would like to get educated from you all as if there are any legal

requirements (time limit) to sign off a chart (Encounter) in any EMR

so that it cannot be modified.

I know paper charts can be changed anytime to correct any mistakes or

errors in documentation, but in the EMR world, once you sign it,

that's the final word. I know you can add addendums to any particular

date encounter.

The EMR we use (Amazing Charts) does not allow you to proceed further

to create a super bill until you sign of an encounter. I have a

workflow issue with that restriction, but that is another issue. I

know other EMRs people are using and few if not a lot of physicians do

not sign off their encounters even until it is paid, even for months.

This way they can make adjustments to their documentation if

required, and even add or omit some facts for their benefit in a legal

situation.

Please share your legal expertise or knowledge.

Thanks in advance!

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