Deleting Treatment Notes in axiUm

Policy: Deleting Treatment Notes in axiUm

Effective Date: June 10, 2013
Revision Dates:

Background and Purpose

Occasionally, treatment documentation/notes are inadvertently entered under the incorrect patient or under the incorrect treating provider. While the School of Dentistry emphatically prohibits the sharing of logins and passwords (including axiUm swipe cards), it also recognizes that infrequent mistakes do occur. This policy clarifies when the deletion of treatment notes is appropriate.

Policy

The School of Dentistry prohibits partial and/or entire treatment documentation/note deletion except in the following circumstances:

  1. The documentation/note was entered under the incorrect patient
  2. The documentation/note was entered under the incorrect treating provider

Documentation/note revisions and amendments are subject to the School of Dentistry’s “Amendment Policy for the Electronic Health Record”  Deleted notes are recorded in axiUm and if needed for audit, they can be recovered.

Procedure

  • Deletion privileges will be given to each Department Administrator, Clinic Manager and Clinic Supervisor. As a back-up, deletion privileges will be given to the School’s Associate Dean for Clinical Services, Patient Care Coordinators, Compliance Analyst and Compliance Director.
  • Requests for documentation/note deletion will be directed to the Department Administrator, Clinic Manager or Clinic Supervisor in the department or clinic where the service/treatment was performed.
  • Individuals with deletion privileges will delete the documentation/note only if it meets the circumstances stated above and below:
    1.  The documentation/note was entered under the incorrect patient
    2. The documentation/note was entered under the incorrect treating provider
  • Comments are not entered into axiUm when deleting notes. Deleted notes are recorded in axiUm and the reason for deletion can be easily determined.

Dean of UW SOD:

Jean Garber, Assistant Dean, Finance & Administration
June 10, 2013