Accidentally copied and pasted into wrong patient note

[ResidentAnonymous001]

Hi guys,

Today I accidentally copied another patient's 1-liner assessment into my other patient's chart. Created an addendum (as I can no longer edit the text) and called IT to see if they can go back and delete it.

Wondering if anyone has ever been able to go back and edit an electronic note for an error? Worried about a HIPPA violation. Anything else I can do at the moment?

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[RangerBob]

I make errors all the time in my notes. So do the other docs. Most are small/innocent ones like dictation errors we didn’t proofread correctly.

Can you not delete the note yourself? Just copy the old note, start a new one, edit out the error, and then sign that.

Obviously in the future proof-read better. But we all make mistakes.

There’s no HIPAA violation if the information wasn’t disclosed to anyone unauthorized (ie, if the other patient hasn’t yet had access to the note— some systems give immediate access now). So IT’s job is to keep that from becoming a HIPAA violation, as they have the power to edit/delete the note if you don’t.

 

[ResidentAnonymous001]

I make errors all the time in my notes. So do the other docs. Most are small/innocent ones like dictation errors we didn’t proofread correctly.

Can you not delete the note yourself? Just copy the old note, start a new one, edit out the error, and then sign that.

Obviously in the future proof-read better. But we all make mistakes.

There’s no HIPAA violation if the information wasn’t disclosed to anyone unauthorized (ie, if the other patient hasn’t yet had access to the note— some systems give immediate access now). So IT’s job is to keep that from becoming a HIPAA violation, as they have the power to edit/delete the note if you don’t.

Unfortunately, I cannot delete it. Yes, the patient is still hospitalized so it would not have been disclosed.
Will just wait for IT to delete. Thank you for your help!

 

[ResidentAnonymous001]

In some EMRs (Cerner for example) you can mark a note "in error" - you can still go in and view the note but it will pop up and say "this note is in error, are you sure you want to view?" or something like that. But yeah, hopefully IT can help you with that as well.

Okay, I think I have seen that before. I appreciate it.

 

[NontradICUdoc]

happens to the best of us jimbo

 

[IonClaws]

Hi guys,

Today I accidentally copied another patient's 1-liner assessment into my other patient's chart. Created an addendum (as I can no longer edit the text) and called IT to see if they can go back and delete it.

Wondering if anyone has ever been able to go back and edit an electronic note for an error? Worried about a HIPPA violation. Anything else I can do at the moment?

Just curious, are you using the EMR they use at the VA? If so, there isn't a way to delete the old note AFAIK, you just have to mention in your addendum it was in error.

 

[ortnakas]

Meditech had a way to delete wrong notes in residency you just had to call medical records. If meditech can do it, I’m sure your EMR can too.

 

[0ncogene]

Have done this a few times. Just delete (put error as the reason) and paste it on the correct patient.

 

[90sportsfan]

I think all hospitals or medical systems should have some kind of an “EHR compliance person” (the title will vary) or EHR records person. I would probably formally report the error to them. There is probably some kind of documentation required if they “delete” something, even of it was some type of erroneous mistake.

For compliance purposes and internal systems audits, I’m sure they capture when things are deleted, so I would formally report this to someone above IT. That way it doesn’t end up causing issues down the road if it gets flagged during a systems audit.

 

[HemeOncHopeful19]

I think all hospitals or medical systems should have some kind of an “EHR compliance person” (the title will vary) or EHR records person. I would probably formally report the error to them. There is probably some kind of documentation required if they “delete” something, even of it was some type of erroneous mistake.

For compliance purposes and internal systems audits, I’m sure they capture when things are deleted, so I would formally report this to someone above IT. That way it doesn’t end up causing issues down the road if it gets flagged during a systems audit.

I did what OP did once… I took a picture of a cancer and accidentally put it in the wrong patient’s chart.

The nurse manager for our clinic gave me a number to call, and I called medical records and they fixed it for me within like 15 minutes. The guy seemed like he got that call a couple of times a week and I’m sure he documented whatever it was you’re talking about.

It was shockingly easy and quick to solve tbh given how difficult it is anytime I have to call IT, for example.

Now at the VA this is a different story of course.

 

[Redpancreas]

Hi guys,

Today I accidentally copied another patient's 1-liner assessment into my other patient's chart. Created an addendum (as I can no longer edit the text) and called IT to see if they can go back and delete it.

Wondering if anyone has ever been able to go back and edit an electronic note for an error? Worried about a HIPPA violation. Anything else I can do at the moment?

For future readers:
This would bother me too if I did this and there wasn’t a way to delete it. That said, IT is on call 24/7. Stay on the phone until you get assurance that this will be dealt with. Do apologize, but do not fret as this was an honest mistake. There should be no penalty. Try to avoid the process which lead to this mistake.

 

[Zyprexa100]

If you can not delete, you can write please consider this note discarded as it is about another patient. I did that before.

 

[ResidentAnonymous001]

Resolved. Thanks everyone. Please close thread.

 

[gutonc]

Closed at OP request.