When a medical assistant needs to correct an entry in a patient's electronic health record (EHR), which of the following actions should be taken to ensure the integrity of the record?
The original entry should be directly modified to correct any errors, with no need for additional remarks since the electronic system logs all changes.
Make a new note that specifies the change, includes the date and time of the amendment, states the reason for the change, and identifies the person responsible for the modification.
Delete the incorrect entry entirely and create a new, correct entry as if the error never occurred.
Use 'track changes' mode to correct the entry so that the changes are visible to all who access the record.
To ensure the integrity of the patient record, any addendum or correction must be clearly labeled as such, with the current date, time, and reason for the change provided. It should also include the signature or identity of the person making the correction. This maintains the transparency and auditability of the records. Directly changing the original entry without acknowledgment or alteration of the record without stating the reason for the change could be considered falsification and lead to legal troubles.
Other options mentioned would not be considered proper because they either directly alter the original entry without leaving a traceable history (which can be problematic for legal accountability), or do not provide necessary details such as the reason for the amendment.
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Why is it important to include the date, time, reason, and identity when correcting an EHR entry?
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What legal risks can arise from altering an EHR entry without proper documentation?
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How does proper correction of an EHR entry support continuity of care?
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Clinical Competency
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