Modifications needed to the NOTES section of the EHR.

Please modify the format so that the columns that separate the sections can have movable columns such as found in Excell to better view the content.

Tracking changes in NOTES. For transparency, we need to be able to see all changes made to the original note by who made them and what date/time the change was made. Similar to the function found in e-forms in Evident under clinical history/ Patient Progress Notes.

1. Reference CMS CoP. 482.24(c)(1). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24

2. “ All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.”

3. The current process does not comply with the "Legible" requirement as any changes are not visible, therefore not legible. On the legal medical record, we must see all entries, additions and deletions made to documents including the person who enters the information with date and time. In the electronic record, there must be a way to see or retrieve the specific changes made.

4. The current process means hospitals must print the original document, all edited versions and final version to compare side-by-side to see what was changed.

5. For continuity of patient care, we must have documents that are easy to read and reflect all changes in a timely fashion.