Best Practices When Correcting an Entry in an Electronic Medical Record System

It’s no secret that keeping track of physical documents poses several challenges for modern medical practices. Over the last few decades, more and more practitioners have switched to an electronic medical record system (EMR).

These digitized medical records offer medical and administrative professionals increased efficiency and ease of use when maintaining and organizing patient records.

As with other forms of medical record-keeping, EMR data must be properly stored, maintained, and updated. Mistakes happen, though. Sometimes, it is necessary to make corrections to existing medical records.

In these situations, industry professionals need to follow the proper protocols to maintain the integrity of their records and support critical legal standards governing patient privacy and data security. Let’s take a closer look at the best approach when correcting an entry in an electronic medical record system.

What is an EMR?

First, let’s ensure we’re on the same page about an EMR. An EMR is a type of medical record that is created or uploaded to a provider’s digital database. Electronic medical records are maintained by a provider for extended periods of time and are meant to include comprehensive information about a patient’s medical and treatment history. 

The terms EMR and EHR are sometimes used interchangeably because each of these record-keeping approaches serves a similar purpose. However, an EHR or electronic health record is not unique to a single provider. It can instead be accessed by numerous medical professionals and institutions, while an EMR is practice-specific and only intended for use by a particular provider or office. 

Can You Correct an EMR?

Different providers have different preferences when it comes to taking notes. Some medical professionals input all patient data and appointment information directly into a computer for digital record-keeping, while others take physical notes and digitize them after the fact. 

Regardless of the approach, providers are sure to find themselves regularly needing to correct a patient’s record in the EMR for one reason or another.

Perhaps a transcription error occurred while digitizing a hard copy of an intake form, or a patient provided clarification after their appointment about their current medication dosage. In these situations, updating a patient’s EMR record is essential to prevent potentially dangerous errors or missteps during treatment. 

It is possible to make corrections to a patient’s record, but it’s important to ensure that proper procedure is followed while making any changes, addendums, or replacements. Let’s discuss the recommended protocol when correcting an entry in an electronic medical record system. 

How to Correct an EMR

First and foremost, it’s important to understand that data from an EMR should never be deleted and replaced entirely. On the contrary, it is critical to keep track of all changes and corrections to maintain the most accurate records possible.

For this reason, it is recommended that medical professionals add an addendum to an EMR to denote a correction rather than rewriting the data entirely. Within such an addendum, it is important to clearly state why the addendum was added and articulate the purpose of the correction or changes, helping you capture the correct information in comparison to the original entry.

In other situations, a medical professional may discover gaps in an EMR. Perhaps handwritten appointment notes weren’t digitized in a timely manner, or a patient did not know the answer to a question about his or her family history at the time of an appointment. 

Any late entries to a patient’s EMR should be denoted as such rather than simply added to the record without comment or clarification. In some cases, the fact that the data was initially missing from the record may prove pertinent to further treatment plans or in the event of litigation.

Because of these reasons, it’s important to maintain records that provide a comprehensive account of any and all changes, additions, or errors.

Get More Out of Your EMR

EMR software platforms make it possible for medical professionals to streamline and scale up their record-keeping efforts. Electronic records offer medical practices a higher degree of control over their records and make updating, maintaining, and organizing patient data more efficient and effective.

Those medical professionals looking to go the extra mile with respect to their record-keeping may want to consider partnering with Go Find It for a comprehensive digital medical record solution

Go Find It’s document management platform enables medical professionals to extend the functionality of their existing EMR software to boost productivity and save administrators valuable time and resources.

We offer tailor-made solutions for medical professionals across a wide range of industries, including chiropractic offices, general medical services, and more.

Go Find It’s software platform was designed with data security in mind and complies with major industry regulations and requirements, such as HIPAA.

Patient data is of a particularly sensitive nature, so it’s important for medical professionals to partner with a document management service with industry-specific expertise when updating their record-keeping approach.

Find Support When Correcting an Entry in An Electronic Medical Record System

If you’re interested in learning more about Go Find It’s software offerings, we would love to share with you how medical practices across the country have implemented our solutions to optimize their record storage and maintenance procedures.

When correcting an entry in an electronic medical record system is at the top of your to-do list, you can rely on Go Find It to help make this process easier.

Reach out today to speak with a member of our team about scheduling a demo of our suite of document management software solutions. We will be glad to show you how our solutions can support your existing EMR software and workflows.