Question

In: Nursing

explain how to legally correct an error a nurse makes in documentation

Expert Solution

The purpose of correction or modification in the legal health record is to support and maintain integrity of the health record. All systems are not possible for capable of managing error correction as outlined by the policy.

The correction is of 5 types

- Addendum- new documentation use to add in the original entry.

- Amendment- a separate documentation meant to clarify an entry in the medical record.

- Correction- a change in information to clarify the inaccuracies

- Deletion -to delete the pervious information

- Signed- to identify the write of order, date and time

- Wrong chart – to correct the wrong entry.

Procedure for error correction

- Error correction is done by the person who has done the initial entry. If not possible then authors supervisor or authorized designee make the correction in extenuating circumstances.

- In paper record, draw a line through the erroneous information in the document in a fashion that makes it clear that it is an error, but doesn’t obligate or reduce the ability to read that erroneous information. Sign or initial, date and time the entry. If only initials are used, there must be corresponding entry on the signature identification sheet available in the record for reference.

- All electronic information is correct via amendment or addendum, if electronic record doesn’t mark the error then amendment must be strictly adhered.

- The correct information should be marked adjacent to the original entry as possible.

- Any edits or additions done to a completed/ signed document must be labeled as an addendum.

- Don’t discard the handwritten not containing erroneous entry.

- All entries must be reflecting date and time at which they were made and signed.

- If document was originally created in a paper format and then scanned electronically, the electronic version should be corrected by printing the documentation from the electronic medical record.

FOR ANY DOUBT POST A QUESTION IT WILL BE HIGHLY APPRECIATED.

Nightingale answered 2 years ago

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