Wiki Dictation question

[suela923@aol.com]

When reading a dictated report and a typo is found that does not affect the actual coding of the procedure is it necessary to have the doctor do an addendum to correct the error?
Thanks.

 

[mariapuerto5@gmail.com]

Dictation Question

Yes, it is necessary that the patient medical record contains accurate information. The provider could do an addendum to the note and/or follow the below steps in documenting their correction.

Record Entries Guidelines states:

To Make corrections to the medical record by the provider:
- line through the incorrect information;
- correct the information entered incorrectly; and
- initial and date the corrections

Do not:
- white out;
- black out;
- erase; or
- cover up an area in any way

I hope that this answer your question.

Thanks,
Maria Puerto