Page 35 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

is doing what and when they are doing it so as to avoid even the

suggestion of subterfuge.

 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, 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 3-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:

 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

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