Page 36 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

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 3

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 (EHRs), 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, 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.
6

Organizations should clearly define for providers that once a

document has a final sign-off, the only way to correct or revise the

documentation is to provide an addendum. The organization

6 https://www.medscape.com/viewarticle/804731_2

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