Page 38 - Risk Reduction Series - Documentation Essentials (Part One)
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SVMIC Risk Reduction Series: Documentation Essentials
Protocols should clearly indicate that once a document
has a final sign-off, the only way to correct or revise the
documentation is to provide an addendum to the health record.
Some EHRs will not allow editing or correction of entry errors
made in progress notes. While the error may persist in several
locations in the EHR which cannot be edited, it is nevertheless
important to create an addendum to correct the error.
If unsure whether a change to the chart is appropriate, please
call an SVMIC claims attorney to discuss the particular situation
and receive guidance.
The concern with well-intentioned changes to the medical
record following a known adverse event potentially creating
more of a defensibility challenge is illustrated in the following
case.
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