Ophthalmology and Optometry Coding Alert

Question: How should we correct a mistake in an electronic health record (EHR)?

Washington Subscriber

Answer: If errors occur in a medical record, regardless of whether the record is electronic or on paper, it should be legibly corrected to allow the reviewer to understand how and when it occurred. Ideally, when a healthcare provider corrects a documentation error, they should note the date and time of the change. The person making the adjustment should also sign or initial the entry in the EHR.

Even though the information is inaccurate, the content shouldn’t be removed from the EHR. This lets an auditor read both the original entry and the addendum.

Example: An ophthalmologist accidentally copies and pastes information from one patient’s record into another patient’s record. Weeks later, another staff member notices the error.

Regardless of whether the provider placed the information in the wrong patient’s record, or the information is false for that specific patient, the healthcare professional correcting the information should do so with an appropriate method. One way to fix the mistake in a paper world is to cross out the information and initial above it with the reason, date, and time of the correction. In an electronic world, an addendum can be created with the reason for the addendum and the correction. The addendum will automatically be date- and time-stamped in an EHR.