When an error is made in a medical record entry, the original entry must not be obliterated, and the inaccurate information should still be accessible.
The correction must indicate the reason for the correction, and the correction entry must be dated and signed by the person making the revision. Examples of reasons for incorrect entries may include “wrong patient,” etc. The contents of Medical Records must not otherwise be edited, altered, or removed. Patients may request a medical record amendment and/or a medical record addendum. (Refer to UC__ policy for handling patient requests for record amendment and record addendums.)
A. DOCUMENTS CREATED IN A PAPER FORMAT:
1. Do not place labels over the entries for correction of information.
2. If information in a paper record must be corrected or revised, draw a line through the incorrect entry and annotate the record with the date and the reason for the revision noted, and signature of the person making the revision.
3. If the document was originally created in a paper format, and then scanned electronically, the electronic version must be corrected by printing the documentation, correcting as above in (2), and rescanning the document.
B. DOCUMENTS THAT ARE CREATED ELECTRONICALLY MUST BE CORRECTED BY ONE OF THE FOLLOWING MECHANISMS:
1. Adding an addendum to the electronic document indicating the corrected information, the identity of the individual who created the addendum, the date created, and the electronic signature of the individual making the addendum.
2. Preliminary versions of transcribed documents may be edited by the author prior to signing. A transcription analyst may also make changes when a non-clinical error is discovered prior to signing (i.e., wrong work type, wrong date, wrong attending assigned). If the preliminary document is visible to providers other than the author, then this document needs to be part of the legal health record.
3. Once a transcribed document is final, it can only be corrected in the form of an addendum affixed to the final copy as indicated above. Examples of documentation errors that are corrected by addendum include: wrong date, location, duplicate documents, incomplete documents, or other errors. The amended version must be reviewed and signed by the provider.
4. Sometimes it may be necessary to re-create a document (e.g., wrong work type) or to move a document, for example, if it was originally posted incorrectly or indexed to the incorrect patient record.
C. WHEN A PERTINENT ENTRY WAS MISSED OR NOT WRITTEN IN A TIMELY MANNER, THE AUTHOR MUST MEET THE FOLLOWING REQUIREMENTS:
1. Identify the new entry as a “late entry”
2. Enter the current date and time – do not attempt to give the appearance that the entry was made on a previous date or an earlier time. The entry must be signed.
3. Identify or refer to the date and circumstance for which the late entry or addendum is written.
4. When making a late entry, document as soon as possible. There is no time limit for writing a late entry; however, the longer the time lapse, the less reliable the entry becomes.
D. AN ADDENDUM IS ANOTHER TYPE OF LATE ENTRY THAT IS USED TO PROVIDE ADDITIONAL INFORMATION IN CONJUNCTION WITH A PREVIOUS ENTRY.
1. Document the date and time on which the addendum was made.
2. Write “addendum” and state the reason for creating the addendum, referring back to the original entry.
3. When writing an addendum, complete it as soon as possible after the original note.
E. ERRORS IN SCANNING DOCUMENTS
If a document is scanned with wrong encounter date or to the wrong patient, the following must be done:
1. Reprint the scanned document.
2. Rescan the document to the correct date or patient, and void the incorrectly scanned document in the permanent document repository.
F. ELECTRONIC DOCUMENTATION – DIRECT ONLINE DATA ENTRY
Note: The following are guidelines for making corrections to direct entry of clinical documentation, and mechanisms may vary from one system to another.
1. In general, correcting an error in an electronic/computerized medical record should follow the same basic principles as corrections to the paper record.
2. The system must have the ability to track corrections or changes to any documentation once it has been entered or authenticated.
3. When correcting or making a change to a signed entry, the original entry must be viewable, the current date and time entered, and the person making the change identified.
G. COPY AND PASTE GUIDELINES
The “copy and paste” functionality available for records maintained electronically eliminates duplication of effort and saves time, but must be used carefully to ensure accurate documentation and must be kept to a minimum.
1. Copying from another clinician’s entry: If a clinician copies all or part of an entry made by another clinician, the clinician making the entry is responsible for assuring the accuracy of the copied information.
2. Copying test results/data: If a clinician copies and pastes test results into an encounter note, the clinical-provider is responsible for ensuring the copied data is relevant and accurate.
3. Copying for re-use of data: A clinician may copy and past entries made in a patient’s record during a previous encounter into a current record as long as care is taken to ensure that the information actually applies to the current visit, that applicable changes are made to variable data, and that any new information is recorded.