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Rob
2016-03-08
It runs smoothly and quickly. It appears to have every feature I need in my daily work with PDF files, except one. It would be a fully completed utility if it included options for arranging/rearranging pages in PDF files. If it has that feature I am unable to find it. With this feature I'd rate it 5 stars.
Jannett C
2016-09-22
I don't need legal documents very often & purchased to help a friend get through a difficult time. much better than hand writing all of the documents out. makes it look professional and I will probably use in the future as well, if needed.
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Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.
Is it appropriate to change the chart entry?
It is always appropriate to make chart changes that are necessary to protect a patient's health status. ... Failure to correct that error could endanger the patient. Change such an error as soon as it is discovered by making a single line through the incorrect entry that does not obliterate the prior entry.
How do you correct an error in a patient's chart?
Draw line through entry (thin pen line). Make sure that the inaccurate information is still legible.
Initial and date the entry.
State the reason for the error (i.e. in the margin or above the note if room).
Document the correct information.
How do you correct documentation errors?
Don't obliterate the mistaken entry. ...
Make the correction in a way that preserves the original entry. ...
Identify the reason for the correction. ...
Follow facility policy when adding late information. ...
Never alter words or numbers after you've written them. ...
Correct mistakes promptly.
How long does it take to correct a medical record?
In general, physicians are required to provide the records in a timely manner (as soon as reasonably possible, but no later than 30 days after the request).
How are errors in an electronic health record corrected?
In general, a narrative entry in the medical record statement indicating that an error has been made, and is being corrected, is the best procedure. ... Work with your vendor to confirm that your EHR system allows error correction and determine whether the vendor has established a process.
Why is a patient's chart considered a legal document?
The medical record contains valuable information about a patient's medical history and individual clinical interactions. ... In addition to its clinical significance, the medical record is also a legal document that can serve as evidence of the care provided.
What constitutes a legal medical record?
A legal health record (LHR) is the documentation of patient health information that is created by a health care organization. The LHR is used within the organization as a business record and made available upon request from patients or legal services.
What is the purpose of the medical record?
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
Can medical records be used in court?
When a medical record is at issue in state litigation against a medical care practitioner, other than cases brought by the patient, medical records will be protected from discovery unless the plaintiff can show a compelling reason why the records are necessary to prove its case.
Is falsifying medical records a crime?
Falsification of a medical record with any kind of alteration or destruction is considered as tampering with evidence in a medical malpractice case. ... Finally, knowingly falsifying medical records is a felony crime with a potential fine of $250,000 or five years in prison.
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