Certified Medical Assistant (CMA AAMA)Communication and Legal/EthicalHard
A medical assistant accidentally documents a patient's allergy to penicillin as 'no known allergies' in the EHR. Upon realizing the error, which of the following is the CORRECT way to rectify the mistake in an electronic health record?
- AAdd an addendum to the original entry, stating the correction and the reason for it.
- BDelete the incorrect entry and re-enter the correct information.
- CDraw a single line through the incorrect entry, write 'error' and initial, then add the correct information.
- DImmediately create a new entry with the correct allergy information and a note to disregard the previous entry.
Show answer & explanationAnswer & explanation
Correct answer: A. Add an addendum to the original entry, stating the correction and the reason for it.
In an electronic health record, errors should never be deleted. The correct procedure is to add an addendum (or amendment) to the original entry. This addendum should state the correction, the date and time of the correction, and the reason for the change, ensuring an auditable and transparent record.
Why the other options are wrong
- B. Deleting information in an EHR compromises the integrity of the medical record and is generally not allowed.
- C. This is the method for correcting paper charts, not electronic health records.
- D. While creating a new entry is part of the solution, simply noting to disregard the previous one isn't sufficient; the original entry needs to be formally amended.
EHR Error Correction
The process of correcting mistakes in an electronic health record, which requires maintaining the integrity of the original entry while clearly documenting the correction.
- Never delete entries in an EHR.
- Use addendums or amendments.
- Corrections must be dated, timed, and signed/initialed.
Memory trick: Amend, Don't Delete; Date, Time, and Reason.