Correcting EHR notes: a malpractice red flag?

February 17, 2006

If I notice an error in visit notes that I've entered into an electronic health record, how do I go about correcting it so it doesn't look as if I'm altering the record?

Q: If I notice an error in visit notes that I've entered into an electronic health record, how do I go about correcting it so it doesn't look as if I'm altering the record?

A: A good electronic record system will prevent you from making any changes once the record is "signed." So you'll need to make a new entry with the correct information. It should reference the prior note and explain that it contains replacement information to correct the error.