LSS Hints: Canceling a Document

A document can be canceled before it is signed.  If you have documented on the wrong patient, or have used the wrong template, the note can be canceled. 

To do this, use the Documentation tool.

1. Select Documents tab from the sidebar menu to open the documentation menu.  The incorrect document should appear.  Click on the Edit/Amend footer button to open up the document.
2. Click on the Nurse Note toggle button to open up the nursing partion of the document.
3. If vitals had previously been entered, they need to be deleted.  Click on the Vitals field to open up the vitals box, and then click on Update button.  This will open up another window where you can pick Delete Set.  Then click on Save button, and the OK button.
4. If any medications were entered into the document, then enter the orders portion (AOM) and then the medication section.  Cancel any new medications entered incorrectly into the chart.  See here for how to cancel medications.
5. If any allergies were entered while using this encounter, delete these through the allergy function.
6. Now save the document by clicking the OK footer button.  Save the document a second time, by clicking on the Save document footer button again.  This will cause the Sign Menu to appear.  Select the Cancelled option in the Sign Menu and then select Save again.  A new window will popup to allow you to enter the reason the document was cancelled. 
7. Enter the reason the document is being cancelled, such as "Wrong Encounter", "Wrong patient".
8. Go to the APR and reverse or void the encounter.

If a note has been signed by a provider, it cannot be cancelled.  IT will have to be contacted to "unsign" the document.

If you have entered vitals in the note to be deleted, create a new note before cancelling the old note.  In the Vitals section of the new note, click on the Vitals area and the vitals from the old note will be pulled into the new note.  Now, you can go back and cancel the old note.

Vital signs can only be pulled forward from documents associated with the same encounter number.  Vitals taken for a visit with one physician cannot be pulled into a note associated with another provider.

If medications, allergies or PFSH were also entered erronously on the wrong chart, be sure to correct these by entering into the appropriate functionality of the wrong chart.  Just deleting the document will not automatically undo any changes made to medications, allergies, or PFSH in the wrong chart.