Correction to the Medical Record

NESmith

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Please let me know the correct way to make a correction to a medical record and where I can find the information in writing. As always, Thanks for the help.
 

RebeccaWoodward*

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AHIMA has a good article addressing this.

Error Correction Process

When an error is made in a health record entry, proper error correction procedures must be followed:

•Draw a line through the entry. Make sure that the inaccurate information is still legible.
•Write “error” by the incorrect entry and state the reason for the error in the margin or above the note if room.
•Sign and date the entry.
•Document the correct information. If the error is in a narrative note, it may be necessary to enter the correct information on the next available line, documenting the current date and time and referring back to the incorrect entry.

Do not obliterate or otherwise alter the original entry by blacking out with marker, using whiteout, or writing over an entry.

There is additional information pertaining to EHR's

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028509.hcsp?dDocName=bok1_028509
 

pamela brashear

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correction in EHR

If a patient come in and is seen by and resident the resident signs off notes, note set to supervising MD they sign off the charges come to a workque and reviewed by coder they send a message to resident and supervisor and do not correct this Can a Medical Director do addendum to a note that states I have review the note and corrected the dx code.
 
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