How Is a Correction Made to an Electronic Health Record?

Electronic Health Records (EHRs) are commonly used in hospitals and provide an efficient way to manage patient care. However, mistakes do happen in these systems. Some healthcare professionals are frustrated by these errors.

If you are among those who are concerned about mistakes in hospitals and doctor’s offices, you may be wondering: how is a correction made to an Electronic Health Record?

Read more below to find out the details.

What Is an Electronic Health Record?

In the United States, over 96 percent of hospitals use an Electronic Health Record system (EHR). What is an EHR?

An Electronic Health Record is a digital version of a paper chart that doctors and hospitals used to rely upon for patient records. Electronic Health Records provide a patient-centered record that is instantly available to healthcare providers.

EHRs are vital to the health care system. They include a patient’s medical history, medications, immunization dates, and test results, among other data.

EHRs allow health care providers to make decisions in a more efficient way. Health information can also be shared among multiple providers in a digital format.

However, some healthcare professionals are feeling frustrated with mistakes in this system. For example, one study has indicated that EHRs often make errors with potentially harmful drugs and other medication mistakes.

Data entry mistakes or duplication of records are common errors. Fortunately, there are ways to correct these mistakes and keep a healthcare organization on track.

How Is a Correction Made to an Electronic Health Record?

When mistakes occur, healthcare providers will need to make corrections, or addendums, to patient records. The same practices mostly apply here as correcting paper records.

Three rules reflect this similarity. One is to not obscure the original documentation. A second is to make corrections in a timely manner. And, three is to sign all entries.

However, Electronic Health Records do have some differences. Below are some other recommendations to help with correcting EHRs.

The first recommendation for correcting a mistake made in an Electronic Health Record is to contact the EHR vendor for their error correction methods.

A second step is to not permit the EHR to override data that was already in the system. That will allow a full record of information and past mistakes. In general, a healthcare organization should use an EHR​ system that can track changes.

Third, you should write an account of the error in the medical record. Doctors should flag health records to reflect that it has been amended. The updated record should include how the mistake was corrected.

Overall, it is important to develop a clear, uniform process for amending and correcting patient records that all healthcare professionals can follow.

You can also find out more about this topic here: how is a correction made to an EHR or EMR?

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