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Risk Tip: Consistency Key for Medical Records Corrections
Posted on: 10/4/2013

Installing a practice-wide, definitive system for correcting paper and EHR-based medical record errors is an important step in avoiding potential litigation.

If a medical record correction must be made, follow these best practices to manage your risk. 

Paper-based corrections

  1. A single line should be drawn through the error.  
  2. The correct information should be entered above it or to its side.
  3. The word "error" should be written. 
  4. The person making the corrections should initial and date the correction. 

Remember, a paper error should never be obliterated with correction fluid or by any other means. Also, never squeeze corrections between lines or in the margins of the medical record.

EHR-based corrections

  1. The original entry should be viewable or retrievable.
  2. The date and time of the change should be noted.
  3. The person making the change should be identified.
  4. Edits can be made to notes in draft form or be dictated/transcribed before they are signed off by the physician.

If there is reason to believe that the changes are suspect and would not reflect the actual events that occurred, edits should not be made.

Questions? Contact ISMIE's Risk Management Division at 800-782-4767 ext. 3300, or by email.

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