Health Information Technologies and Processes

Medical Record Correction

  • 1.  Medical Record Correction

    Posted 10-23-2020 17:17
    Do you have a process you would be willing to share on how to correct a DI document from 2014 that stated an incorrect laterality? It doesn't seem feasible to dictate an addendum to the report 6 years later, but maybe that is the right thing to do. I was thinking of creating a form that could be attached to the report that indicates the laterality was incorrect; similar to what we would attach if a patient requested a correction to their record that we could not accommodate. Any thoughts or a policy you would be willing to share?

    Thank you,

    Connie

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    Connie Lovell, CPC, MSOM
    Beatrice Community Hospital
    PO Box 278, Beatrice, NE 68310
    Ph: 402.223.7294
    Email: clovell@bchhc.org
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  • 2.  RE: Medical Record Correction

    Posted 10-26-2020 08:28

    Hi, I believe in instances when these types of errors are legit, I would be ok with an addendum. The addendum would have to be clear on the reason for it and transparent on the date and time it was entered.

     

    Thanks,


    Karla

     






  • 3.  RE: Medical Record Correction

    Posted 10-26-2020 16:23
    You raise a great question and I'm interested in the responses you get. We wouldn't be able to have anyone dictate or type an addendum on anything that was from 2014 as we have changed systems since that time. The report is no longer in a format that would be able to be edited or amended, only viewed.

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    Kathryn Wood, RHIA
    Assist Dir of Information Systems/Privacy Officer
    War Memorial Hospital
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