Page 37 - Part One Risk Reduction Series - Documentation
P. 37
SVMIC Risk Reduction Series: Documentation
should have a specific policy and procedure addressing how
addendums are made in the health record.
7
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 case of a 17-year-old
female patient with a 5-month history of myasthenia gravis,
diagnosed and treated by the nurse practitioner. The patient
presented to the office with weakness, slurred speech, and
difficulty swallowing. The slurred speech was documented in the
note. The documentation in the electronic medical records
revealed that the patient was examined by the NP and given
prescriptions for steroids and pyridostigmine. The supervising
physician never saw the patient and was not consulted on the
care, but signed off on the records.
She suffered respiratory arrest at home the following day and her
mother called 911 and performed CPR until emergency services
arrived. Although she was successfully resuscitated, unfortunately,
7 http://journal.ahima.org/2012/08/29/new-toolkit-provides-guidelines-for-ehr-amendments/
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