Certified Medical Assistant (CMA AAMA)Communication and Legal/EthicalMedium
A medical assistant is reviewing a patient's medical record and notices an entry from a previous visit that contains a factual error. The entry was made by another medical assistant. Which of the following actions should the medical assistant take?
- ACross out the incorrect entry with a single line, write 'error' and initial it.
- BInform the patient about the error and ask them to sign an amendment form.
- CDelete the incorrect entry and re-enter the correct information.
- DMake a new entry to correct the error, referencing the original entry and initialing the correction.
Show answer & explanationAnswer & explanation
Correct answer: D. Make a new entry to correct the error, referencing the original entry and initialing the correction.
Correcting errors in medical records requires maintaining the integrity of the original, even if incorrect. A new, dated, and initialed entry that references the error is the correct procedure, ensuring transparency and accountability.
Why the other options are wrong
- A. This method applies more to paper charts where physical alteration is necessary; in EHRs, a new entry is preferred.
- B. While patients have a right to request amendments, the initial responsibility for correcting a factual error lies with the healthcare provider's staff following proper procedure.
- C. Deleting entries is never acceptable as it compromises the legal integrity of the record.
Medical Record Correction
The process of amending an incorrect entry in a patient's medical record while preserving the original information.
- Never delete or obscure original entries.
- Corrections must be dated, timed, and initialed.
- New entries should clearly state they are corrections to previous information.
Memory trick: Record right, correct bright, never delete light.