What should be done if a correction is needed in an electronic medical record?

In the context of electronic medical records, it is essential to adhere to proper protocols when correcting errors to ensure integrity, accuracy, and compliance with legal and ethical standards. Following facility guidelines for correcting errors is the best practice because these guidelines are typically designed to maintain a clear and accurate medical record, while also providing a transparent method for documenting changes.

When an error in an electronic medical record is identified, it is crucial to document the correction appropriately rather than deleting the erroneous entry outright or simply noting it verbally. Deleting an entry can lead to a lack of accountability and may create confusion regarding the patient's medical history. Similarly, documenting the error without any correction does not resolve the issue and can perpetuate misinformation. Verbal notes do not provide a coherent and legally recognized method of documentation in patient records.

By following established facility guidelines, healthcare providers can ensure that all corrections are made in a standardized manner, preserving the integrity of the medical record and improving the overall quality of patient care. This approach also typically includes a timestamp and an explanation for the correction, which contributes to the transparency and accuracy of the medical record.