Instinct is a legal medical record and therefore follows best practices. You can edit treatments for up to 12 hours (think a full shift) after completion and beyond that you can still add an addendum.
How to Correct a Mistaken Entry on the Tx Sheet
Mistakes happen! For example, you may be entering a patient's weight and accidentally enter it in pounds vs kgs, or record the patient's temperature incorrectly. In these cases, where an incorrect entry has been completed on a patient's Treatment Sheet, these errors can be corrected by following the steps below.
1. Find the order on the Tx Sheet for the incorrect entry, select the 3 dot menu next to it and then "Order History":
2. This will open up the Order History screen where you can see the history for the order, and edit any entries. Select the 3 dot menu to the bottom right of the incorrect entry and select "Edit":
3. Now you can remove the incorrect entry and type in the correct entry for the patient and "Save".
4. Also, you can select Edit to adjust the time the treatment was completed:
Because Instinct is a legal medical record, nothing can be truly “deleted”. But, any treatment ordered by accident (or even on the wrong patient), can be discontinued using the 3 dot menu to the left of the order. You can also add an order note to include d/c details. If it was already marked as completed by accident, you can simply edit it and change it to a “Not Completed” item with a note.
These items are essentially voided (which is a legal way to indicate that they were not part of the patients visit).
For example, a weight was accidentally recorded but the patient was not actually weighed, you can follow the steps above but remove the incorrect value in the text box and leave it blank. Make notes (eg. accidentally entered weight") and select "Save & Change to NC (not completed).
The entry will now look like this:
