Certified Medical Assistant (CMA AAMA)Communication and Legal/EthicalHard
A medical assistant is reviewing a patient's medical record for a follow-up appointment. They notice that a previous entry made by a colleague contains a factual error regarding the patient's allergy status. The original entry states 'No known drug allergies (NKDA),' but the patient's intake form clearly lists an allergy to penicillin. What is the correct procedure for the medical assistant to rectify this documentation error?
- AInform the physician to correct the error, as only physicians can alter medical records.
- BDelete the incorrect entry and re-enter the correct information.
- CCross out the incorrect entry with a single line, write 'error,' initial and date it, then add the correct information.
- DAdd a new entry stating the correct allergy and refer back to the incorrect previous entry.
Show answer & explanationAnswer & explanation
Correct answer: D. Add a new entry stating the correct allergy and refer back to the incorrect previous entry.
In electronic health records (EHRs), directly deleting or 'crossing out' as in paper charts is not the standard. The correct procedure is to add an addendum or a new entry that clarifies and corrects the previous error, referencing the original entry. This maintains the integrity of the record and ensures an audit trail of all changes. The original erroneous entry must remain visible.
Why the other options are wrong
- A. While the physician should be informed of critical errors, medical assistants can and should correct their own or a colleague's factual errors in the appropriate manner, especially if it's within their scope of documentation.
- B. Deleting information is never acceptable in medical records, as it removes the original entry and can be seen as an attempt to conceal information.
- C. This method is used for paper charts. In EHRs, this is typically handled by an addendum or correction entry that links to the original, leaving the original visible.
EHR Error Correction
The precise and legally compliant method for rectifying mistakes in a patient's electronic health record, ensuring transparency and an audit trail.
- Never delete original entry.
- Add an addendum or new entry.
- Clearly state 'correction' or 'addendum'.
- Include date, time, and initials of the corrector.
- Explain the reason for the correction.
Memory trick: Never Delete, Always Amend; Keep the Original, Add a New Entry, Initial, and Send!