Allegheny Messages

Available with software version updates released 8/21/14 or later, two overrides are now available that are specific to Addendums.  Addendums as a new feature were requested by several agencies.   Software capability to provide an original document date and signature along with any subsequent late entries or corrections was needed due to  requests by state surveyors and for instances when medical record reviews were requested.  Addendums have also been provided to assist agencies with HIPAA requirements related to data integrity standard 164.312 (c)(1) in the security Standards, Technical Safeguards as agencies “implement policies and procedures to protect electronic protected health information from improper alteration or destruction”.  As guidelines for clinical note writing and incorporation into the clinical record can differ according to state or other certifying body regulations, a new override has been added to allow an agency to indicate a different time frame for document locking then the default of 48 hours.  Agencies will be able to enter 3-14 days.  The override can be found in Other Set up, System Overrides tab, Security tab.  In the same tab we have also added an override to turn off Addendums as a feature for those agencies who have determined/documented the feature is not needed to maintain document integrity and/or may have other policies and procedures in place to maintain original document dates and signature and capture document addendums.

In approximately 2 weeks the software will begin to require an addendum for all visit assessment types, HHA care Plans, PT, OT and MSW assessments.  When clinicians exit one of the listed document types, the clinician will be asked if the document is complete.  If ‘YES’ is selected the software will not allow the document to be opened to the data entry fields.  Instead the clinician will be required to select the Addendum button to complete the data entry of the correction or late entry.  If the agency is using the Electronic Approval feature, clinicians will still electronically approve the original document.  Clinicians will be asked to electronically approve all addendums.  The print form will include the original document and electronic approval along with any addendums and the electronic approval.  If the clinician answers ‘NO’ to the question “Is this document complete?”, the software will give the clinician until the end of the next calendar day to complete the documentation.  After that time point the software will require any additional documentation to be made as an addendum.  In the Point of care software, only the employee who created a document will be able to make an addendum to that document.  The ability to attach an addendum to a document in the main office software will require an additional system security setting for the allowed employee.

Addendums for OASIS and Hospice (CA) documents will be released at a later time.  Please monitor Allegheny Messages for further updates for Addendums to OASIS documents and Hospice Assessments