Page 37 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

• The date of the note and your initials

• The new information

• The reason why this information was not included in the
original entry

• How the new information affects the follow-up or treatment
plan

For example, a brief, factual addendum might look like the

following:

Addendum to 11/25/2016 note. Telephone call to Ms. Williams
to discuss labs. She then reported pain in her right calf for

three weeks following a recent vacation to Europe. Doppler
study scheduled for 11/27/2016.

Now that the majority of healthcare professionals have
transitioned to electronic health records, policies and

procedures for amending records should reflect that change.
Amending records in an EHR should follow the same basic

principles as in a paper chart. Work with your vendor to confirm
that your EHR allows error correction and determine whether

the vendor has established a process. The system must have the
ability to track corrections or changes once the original entry

has been entered or authenticated.

When correcting or making a change to an entry, the original
entry should be viewable (i.e., not deleted), the current date and

time should be entered, the person making the change should
be identified, and the reason for making the change should be

noted. If a hard copy has been printed from the EHR, the hard
copy must also be corrected.
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6 https://www.medscape.com/viewarticle/804731_2

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