tci ED Coding & Reimbursement Alert - 2024 Issue Q3

Reader Questions: Rely on Addendums for EHR Mistake Corrections

Question: How should we correct a mistake in an electronic health record (EHR)? Montana Subscriber Answer: If errors occur in a medical record, regardless of whether the record is electronic or on paper, then it should be legibly corrected to allow the reviewer to understand how and when it occurred. Ideally, when a healthcare provider corrects an error, they should note the date and time of the correction. The person making the adjustment should also sign or initial the entry in the EHR. Even though the information is inaccurate, the content shouldn’t be removed from the EHR. This...

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