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How to Modify Medical Records: A Step-by-Step Guide

Learn how to edit transcribed medical documents such as H&Ps, discharge summaries, and op notes. Follow the steps to make necessary modifications and add comments for scanned documents. Ensure accuracy and compliance with this helpful tutorial.

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How to Modify Medical Records: A Step-by-Step Guide

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  1. Modifying a Document • Edits can only be done on a transcribed document with the document open. • Examples of Transcribed Documents are: • H&P’s • Discharge Summary’s • Op Notes • Steps to Modify a Document: • Right click on the document • Select Modify Lesson 3 Modifying a Document

  2. Modifying a Document • Edit the information within the document as needed In this example the Reason for Consult was modified • Once you are done modifying the document, select Sign if complete • If the document still needs review select Save or Save & Close Lesson 3 Modifying a Document

  3. Modifying a Document • The only modifications that can be made to scanned documents • in Message Center are comments that will display in the Document • Description pane. • To enter/modify comments on a scanned document, complete the • following steps: • Right click on the document • Select Modify Lesson 3 Modifying a Document

  4. Modifying a Document • Type/edit the information as necessary in the designated pane DO NOT click the Import button. This feature will not be implemented at this time. Enter your comment here. • Once you are done modifying the document, select Sign if complete • If the document still needs review select Save or Save & Close Lesson 3 Modifying a Document

  5. Modifying a Document Important Note!! All comments can be viewed by any user with access to the patient’s medical record. Only comments pertinent to the document should be entered.

  6. To move on to Lesson 4 Proxies, click on the icon below Lesson 3 Modifying a Document

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