What action should an HIM director recommend if transcribed reports are changed by the author after transcription?

What action should an HIM director recommend if transcribed reports are changed by the author after transcription?

• A. Immediately stop the practice of changing transcribed reports
• B. Develop a facility policy defining acceptable time frames for draft documents
• C. Conduct a verification audit
• D. Alert hospital legal counsel of the practice

Answer: (B)

The recommendation to develop a facility policy defining acceptable time frames for draft documents is crucial for maintaining the integrity and accuracy of medical records. This approach allows the organization to establish a clear protocol that outlines when and how changes can be made to transcribed reports after they have been finalized. By setting defined time frames, the facility can ensure that all changes are made transparently and consistently, reducing the likelihood of errors or discrepancies. A well-articulated policy will also facilitate communication among staff about expectations regarding document revisions, foster accountability, and promote compliance with legal and regulatory standards. It addresses the need for flexibility in clinical practice while still ensuring that patient records remain accurate and reflect the most up-to-date information available. The other actions may address urgent concerns or offer reactive solutions, but creating a proactive policy is a comprehensive approach that encompasses ongoing management and education regarding document handling practices.

The recommendation to develop a facility policy defining acceptable time frames for draft documents is crucial for maintaining the integrity and accuracy of medical records. This approach allows the organization to establish a clear protocol that outlines when and how changes can be made to transcribed reports after they have been finalized. By setting defined time frames, the facility can ensure that all changes are made transparently and consistently, reducing the likelihood of errors or discrepancies.

A well-articulated policy will also facilitate communication among staff about expectations regarding document revisions, foster accountability, and promote compliance with legal and regulatory standards. It addresses the need for flexibility in clinical practice while still ensuring that patient records remain accurate and reflect the most up-to-date information available.

The other actions may address urgent concerns or offer reactive solutions, but creating a proactive policy is a comprehensive approach that encompasses ongoing management and education regarding document handling practices.