Amending, Correcting and Voiding in the Electronic Health Record
When an entry is accidently or erroneously entered into the EHR, staff will need to complete the following steps to ensure that the entry is voided appropriately.
When a staff person notices that an entry or document has been entered into the EHR incorrectly, a BAS ticket will be created by that staff member.
The staff member will need to include the following information:
- Client Name
- Client DOB
- Client MRN
- Date of entry
- Type of entry
Why the entry needs to be voided
The ticket will be routed to the Centralized Records staff who will have permission to void the document or entry.
The Centralized Records staff will close out the BAS ticket once the document has been voided.
- Amendments, corrections and delayed entries must be distinctly identified as such and the record must provide a reliable means of clearly identifying the original content, the modified content, and the date and author of each record.
- 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.
- 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 stated below and rescanning the document.
- 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.
- Documents that are created electronically must be corrected by one of the following mechanisms:
- 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.
- 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 circleovered 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.
- 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.
- 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.
- When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements:
- Identify the new entry as a “late entry”
- 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.
- Identify or refer to the date and circumstance for which the late entry or addendum is written.
- 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.
- An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry.
- Document the date and time on which the addendum was made.
- Write “addendum” and state the reason for creating the addendum, referring back to the original entry.
- When writing an addendum, complete it as soon as possible after the original note.
- Errors in Scanning Documents
- If a document is scanned with wrong encounter date or to the wrong patient, the following must be done:
- Reprint the scanned document.
- Rescan the document to the correct date or patient, and void the incorrectly scanned document in the permanent document repository.
- 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.
- In general, correcting an error in an electronic/computerized medical record should follow the same basic principles as corrections to the paper record.
- The system must have the ability to track corrections or changes to any documentation once it has been entered or authenticated.
- 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.