Under certain circumstances, a medical health-care provider may find it necessary to make changes to a medical record. Understanding the legal way to do so, and the standards for which such changes may apply, enable medical personnel to correctly and professionally make such changes.
Correcting Notation Errors
A medical record must be accurate and contain information regarding diagnosis and treatment of a patient. However, there are times when a health-care provider such as a nurse inadvertently makes an error when inserting information regarding care or medication administration. In such cases, the error must be amended. The standard and legal way to amend medical record errors is to add the correction to the medical record. If the mistake has just occurred, the health-care provider is required to indicate the error by marking the word or sentence with a single line through the text. The corrected information is then added, as well as the time, date and initials of the health-care professional making the change. In no circumstance should the erroneous information be blocked out, erased or eradicated with liquid eraser marks.
Patient Requested Changes
At times, a patient may approach a doctor or health-care provider and request a change in his medical record, most often because of a misspelling of a name, a wrong address or a wrong date or diagnosis. The patient's doctor is required to make changes or corrections as an addendum to the record noting the change. If the doctor does not feel the change is necessary because it is not incomplete or inaccurate, she must make a statement in the record and add it to the medical record, the request by the patient as well as her comments regarding such a change. A copy of the denial must also be in written form to the patient, stating the reason for the denial. A copy of the denial should also be attached to the medical record.
Adding Information
A health-care provider must provide accurate, timely and correct medical records that are available for review by auditing groups on a yearly basis, most often during inspections for accreditation. Making changes in a medical record is legal as long as it is properly documented, dated and signed. To add information regarding patient care, the documentation regarding the care, as well as the reason for the omission in the medical record in the first place, must be attached to the medical record and signed and dated. Back-dating is not legal and may result in fines or criminal charges.
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