How do you correct an error when charting?

I work in an operating room, where we have EMRs. We check each other's charts for mistakes, sometimes days later. We are told to make corrections if we find mistakes. Is this legal?

Response from Carolyn Buppert, MSN, JD Healthcare attorney, Boulder, Colorado

It's good that you are doing internal audits -- staff learn by analyzing what they are doing right and identifying what they need to improve. It is legal to correct mistakes and make late entries, if it is done appropriately. If not done correctly, it could be illegal and, at minimum, more detrimental than helpful.

With your correction, you need to make it clear that the entry is a late entry and that you are correcting a mistake. You should not try to eradicate the erroneous previous entry. You should not try to make the new entry appear to be the original entry. First, know that there may be state laws that apply to this situation. Hospitals should have policies on how to correct errors in the medical record. Your hospital's legal counsel should be in on the discussion about the policy, should review the state law, and should review the policy.

In general, the appropriate way to correct an error is the same as with paper records -- that is, make a new entry with today's date and time, stating that you are correcting an error in a previous entry; give the date and time of the previous entry; and enter the corrected data or explanation. Without knowing the details of your electronic record, I can't say exactly how to accomplish this, but what you want is for the original entry to be visible, with a notation that alerts a reader that this part of the record has been corrected and directing the reader to the corrected information. The original author of the report should be the individual making the correction. If someone else is making the correction, the new author should explain why he or she is making the correction.

The reason for keeping the original entry is that if there is a challenge to the care or the documentation (for example, a lawsuit filed or a claim for reimbursement rejected), the hospital and clinicians need to avoid any indication that the records have been altered in anticipation of litigation or payer audit. Alteration of records (sometimes called "spoliation of the evidence" in a legal proceeding) is detrimental to the defense of a malpractice action or a claim for payment. The opposing party is entitled to an assumption that the altering party had a "consciousness of guilt." Defense attorneys say it is nearly impossible to defend a hospital in a malpractice case when the record has been altered.

A Website for nurse legal consultants tells attorneys to be alert to signs of tampering with medical records. "Tampering with the record involves any of the following: adding to the existing record at a later date without indicating [that] the addition is a late entry, placing inaccurate information into the record, omitting significant facts, dating a record to make it appear as if it were written at an earlier time, rewriting or altering the record, destroying records, or adding to someone else's notes."[1] If records are altered in anticipation of a payer audit, then the payer, when discovering the alteration, presumes the hospital or clinician has billed fraudulently.

The bottom line is that internal audits are good. When mistakes are identified, focus on educating the clinician about his or her error and how to document better in the future. In general, correcting errors found during internal audits should be done rarely and carefully, without intent to deceive.

Medscape Nurses © 2013  WebMD, LLC

Cite this: Carolyn Buppert. How Should I Make Corrections to Electronic Charts? - Medscape - Aug 23, 2013.

By law, you have the right to correct errors in your medical records. The Health Insurance Portability and Accountability Act (HIPAA) ensures that your medical records are private. Another important part of this law allows you to request amendments to your medical record if you find errors.

This process for making this type of correction can be as simple as just letting your healthcare provider know that something was recorded incorrectly so your healthcare provider can change it.

But sometimes corrections aren't so simple, and you need to familiarize yourself with the rules for amendment of protected health information so that you can get the corrections taken care of.

While many patients are not interested in looking at their own medical records, it is a good idea to do so. According to the Office of the National Coordinator for Health Information Technology, almost 1 in 10 people who access records online end up requesting that they be corrected for a variety of reasons.

Some healthcare systems will provide you with a patient portal that provides easy access to all of your medical records within that system. Even if you don't have that type of access, you are entitled to look at your own medical records and obtain copies. Sometimes there is a cost for getting copies of your records.

Once you have your medical records, you can review them. If you see any inaccuracies, you can determine whether they are important and require an amendment.

Types of errors can include:

• Typographical spelling errors may or may not require correction. For example, if mesenteric is incorrectly spelled "mesentiric," you might not go through the trouble of having it corrected because there won't be any impact on your health or medical care.
• Errors in the spelling of your name do require correction because this can prevent your records from being shared properly among different providers, and it can affect payment for services.
• If your phone number or address is incorrect or outdated, you'll want to make sure it gets corrected immediately. Failure to do so will result in the wrong information being copied into future medical records or an inability for your medical team to contact you if needed.
• Any inaccurate information about your symptoms, diagnosis, or treatment should be corrected. For example, if your record says that you have temporal tumor instead of a testicular tumor, this is completely different and requires correction.
• If the record says your appointment was at 2 pm, but you never saw the healthcare provider until 3:30 pm, that may not have any bearing on your future health or billing information needs, and it isn't worth correcting.

Overall, you have to make your own judgment about which parts of your medical record need to be corrected if you find errors. If you are on the fence, it is better to correct something than to leave it incorrect.

Contact the hospital or your payer to ask if they have a form they require for making amendments to your medical records. If so, ask them to email, fax, or mail a copy to you.

Be clear, concise and write the correction exactly as you think it should be noted. The idea is to make it very easy for your provider's office to amend your records.

Make a copy of the page(s) where the error(s) occur. If it's a simple correction, then you can strike one line through the incorrect information and handwrite the correction.

By doing it this way, the person in the provider's office will be able to find the problem and make the correction easily. If they sent you a form to fill out, you can staple the copy to the form.

If the correction is complicated, you may need to write a letter outlining what you think it is wrong and what the correction is.

If you do write a letter, make sure you include some basics, such as your name and the date of service of your letter, then staple your letter to the copy of the page that contains the error.

The provider or facility must act on your request within 60 days but they may request an extension of up to 30 additional days if they provide a reason to you in writing.

Your provider is required to inform you that they have accepted or denied your request for an amendment in a timely manner. If you requested that other providers, business associates, or others involved in your care are also informed of the amendment, your provider must inform them as well.

Your providers are not required to make the change you request. If they deny your request, they must notify you of their decision in writing and keep a record of your request and their denial in your medical records.

There are a number of reasons that your request could be denied. For example, some patients request that information about drug use, sexually transmitted diseases, violent outbursts, or other sensitive topics be removed.

However, most providers will refuse to remove this information because it has an effect on your health and medical treatment.

Your medical record may appear complicated at first, especially if you aren't used to looking at medical records. But once you start to read it, you will begin to recognize the important features.

If you have any concerns, discuss the matter with your healthcare provider's office–the vast majority of the time, you will get a speedy correction. If that isn't the case, you will need to follow the proper procedures to get things corrected, or at least considered.