When an error is made in a healthcare record, how should it be handled?

The appropriate procedure when an error is made in a healthcare record is to document an addendum to the electronic health record (EHR) or paper-based record while leaving the original entry in place. This method preserves the integrity of the medical record by maintaining a true and complete account of the patient’s history. It allows for transparency and accountability in the documentation process, as the original entry remains intact, providing a full record of what was initially recorded and how it was later corrected.

By adding an addendum, the healthcare provider can clarify the error, explain the nature of the correction made, and ensure that anyone reviewing the record in the future has access to both the original information and the updated context. This practice is aligned with legal and ethical standards governing healthcare documentation, which emphasize accuracy and honesty. Additionally, this approach aids in preventing misunderstandings or misinterpretations that could arise from altering or deleting original entries, thereby fostering trust in the patient-provider relationship and the overall healthcare system.