Question

If a provider needs to make a change to an entry in the electronic medical record,he/she should:

a. Erase the incorrect entry and replace it with the correct information
b. Identify the incorrect entry, and write a signed and dated addendum to the record to make the correction
c. Nothing, records should never be changed
d. Delete the wrong information and write an amendment with the new information

Answer 1

When correcting an entry in an electronic medical record, a provider should write a signed and dated addendum without erasing the original entry, thus maintaining the integrity of the medical record.

Step-by-step explanation:

If a provider needs to make a change to an entry in the electronic medical record, the appropriate action is to identify the incorrect entry, and write a signed and dated addendum to the record to correct the information. This process maintains the integrity of the medical record by preserving the original entry while clearly indicating the updated information. It is crucial to never erase or delete the original entry because the medical record must accurately reflect all the information, even if some of that information is later corrected or amended. Health providers are encouraged to share digital records to improve the quality of healthcare while ensuring the privacy of electronic records is maintained.