Page 36 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

There are times, in the normal course of treatment, when

additions or corrections to a medical record are acceptable,
provided they are made appropriately. To make a correction in a

paper chart, simply draw a single line through the original entry,
make the correction, and then date and initial it. When making

a lengthy correction or an addition to the record, clearly mark
it as an addendum, enter it chronologically in the chart, and

date and sign the entry. Always avoid writing in the margins or
squeezing words between lines, as this can give the appearance

of an alteration even if it is not. Any change to the chart should
make it clear who is doing what and when they are doing it so

as to avoid even the suggestion of subterfuge. Specific to paper
charts:

• Use a pen that is clearly identifiable as different from that
used on the original.

• Draw a single line through the incorrect entry leaving it

legible.

• Print the correction above the error, and then initial and

date the correction as of the date you are making the
correction.

• Never erase an entry, cross it out so that it cannot be read
or use white-out or any other means to render the original

wording illegible.

There are situations when a late entry may be appropriate,
particularly if it affects continuity of care. Assume, for example,

that your patient, in the office for a blood pressure check,
neglected to report a three-week history of calf pain following

a vacation to Europe. She casually mentions this when you
telephone her about the lab results and medication change. The

out-of-sequence entry needs to contain four elements:

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