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When an error is made in a medical record entry, proper error correction procedures must be followed. Draw line through entry (thin pen line). Make sure that the inaccurate information is still legible. Initial and date the entry.
When the physician discovers an error, such as a progress note that has been inserted into the wrong record or is missing, it must be added as an addendum or corrected in the specific manner. When making a correction on a computerized document, maintain the original entry in the electronic file.
A Medical Record Amendment is: A change, edit or update of medical record information requested by the patient when they feel the information documented is incorrect.
Which is the appropriate method for correcting data in a medical record? Remove the item with the incorrect data, and then create a new form with the correct information.
Changing a medical record to correct an error is anything but an easy process. Under federal HIPAA rules, patients have the right to request that doctors fix errors, but the provider has up to 60 days to respond, and can ask for a 30-day extension. The provider also can refuse, but must specify the reason in writing.
If you think the information in your medical or billing record is incorrect, you can request a change, or amendment, to your record. The health care provider or health plan must respond to your request. If it created the information, it must amend inaccurate or incomplete information.
Reasons for Denial.The provider who received the amendment request had not created the original record. The record was created at another office. There is an exception if the creator is no longer available and the mistake in the record is apparent.
Proper Error Correction ProcedureDraw line through entry (thin pen line). Make sure that the inaccurate information is still legible.Initial and date the entry.State the reason for the error (i.e. in the margin or above the note if room).Document the correct information.
Under HIPAA, patients have a right to request amendments to their medical records, but it is up to the provider to decide whether or not to do it. However, regardless of what the provider decides, they must respond to the patient's amendment request.
In general, the appropriate way to correct an error is the same as with paper records -- that is, make a new entry with today's date and time, stating that you are correcting an error in a previous entry; give the date and time of the previous entry; and enter the corrected data or explanation.