The electronic medical record in Tasy: authorship, progress notes and record integrity
What is not in the record did not happen, for the payer and for the courts. The rules that keep the Tasy record intact and how account audit uses it.
The electronic medical record is the patient's document. In Tasy, it brings together progress notes, orders, requests, results and documents, each tied to an encounter, with author, date and time. It serves three purposes at once: care (the team knows what was done), billing (the payer pays for what is recorded) and the hospital's defense (in an audit or a lawsuit, what is not in the record did not happen).
The four recording rules
- Right patient and encounter. Before writing, check the patient and the encounter open on screen. Recording on the previous visit's encounter is common and confuses the history and the account. See safe patient identification.
- Authorship. Each professional records with their own user, within their scope. A note made under someone else's login is false as a document.
- Date and time of the event. The note carries the date and time it was made; when the hospital allows late entries, they follow the rule (with the time of the event and the time of the entry).
- Correct without deleting. Errors are fixed through the amendment process, which keeps the original and the correction, with author and reason. Deleting is not allowed.
What the payer looks for in the record
The payer's audit compares the account with the record. The items checked most:
| Account item | What must be in the record |
|---|---|
| Room charges | Daily notes justifying the stay, in the unit charged |
| ICU | ICU admission criteria and notes for each day |
| Procedures | Description, report or procedure note |
| Supplies and drugs | Order and administration record |
| Implants | Operative note with the material used, label and authorization |
| Professional fees | Professional and role recorded on the procedure |
| Tests | Physician's order and result |
An item charged without the matching record is a certain clinical denial. See hospital claim denials.
Notes that justify the stay
A progress note copied from the day before, unchanged, is a red flag for the auditor. The note that supports a room day answers: how the patient is, what changed, what was done and why they still need to be in that unit. It does not have to be long; it has to be that day's.
Orders, dispensing and administration
An order in the record generates dispensing in the pharmacy and administration in nursing. The three steps must close: what was ordered, dispensed and given. Medication charted without an order, or a stopped order still dispensed, show up in internal audit and in the payer's.
Integrity and access
- Open only the records of patients you care for. Every access is logged (access profiles in Tasy).
- Do not copy text between patients: the risk of carrying one patient's data to another is high.
- Scanned documents (consent forms, outside reports) go into the right encounter, legible and complete.
- Print the record only for the authorized purpose, with secure disposal.
Medical record KPIs
- Missing notes: inpatient days with no physician or nursing note.
- Orders without administration records and administration without orders.
- Discharge summaries pending after discharge.
- Amendments by unit and reason.
- Clinical denials for missing documentation, by payer and item type.
The hospital's medical records committee can use these numbers to choose what to review first.
In outpatients
In an outpatient visit the note is shorter, but the rules are the same: right encounter, authorship, plan and requests. See outpatient visits in Tasy.
Who writes this
Domínio has worked for more than 20 years with hospitals that run Tasy and follows, through denials, the effect of every note missing from the record. To measure how much your hospital loses to missing documentation, talk to us on WhatsApp or at comercial@dominiocontabil.com.br.
Related questions
Can I correct a note I wrote wrong?
Yes, through the hospital's amendment process, which keeps the original note and the correction, with the reason.
Can billing edit the medical record?
No. Billing reads the record for account audit; clinical notes belong to the health professionals.
Is a note copied from the day before accepted?
The system may accept it, but it is challenged in audit. The note has to reflect the day.
How long must the record be kept?
Retention rules come from the law and professional bodies; the hospital follows the retention policy approved by its medical records committee.
Written by the Domínio team behind Clic Health: accountants, controllers and developers with more than 20 years of work with hospitals that run Tasy. Have a question about Tasy? Talk to us on WhatsApp.