Correcting EHR Errors Without Getting Into Trouble

Georgette Samaritan, RN, BSN

Disclosures

May 29, 2013

Legal Implications of Changing EHR Records

State laws vary on how medical records can be amended. Generally, the law frowns on erasing relevant information so that it cannot be recovered. That's why opaque correction fluid should not be used in correcting paper records, and why incorrect entries in the written medical record should be lined out and rewritten rather than obscured.

Overwriting the initial EHR data, even though the information is incorrect, could be construed in a malpractice suit as improper alteration of the historical medical record. In general, states merely require that electronic records be maintained "to the same standards" as paper copies.

Also, the amended EHR record should be flagged to indicate that it has been corrected, and some mechanism should be put in place to retain and easily access copies of the original, if incorrect, data. A comment field in the amended report may suffice.

In general, a narrative entry in the medical record statement indicating that an error has been made, and is being corrected, is the best procedure. When a laboratory or diagnostic report is involved, the facility director or pathologist should assume responsibility for ensuring that such an entry is made. Both the original error and the correction should be well documented for future reference.

Personal contact between the laboratory or diagnostic facility and the involved physician is always desirable and should occur whenever you need to correct an erroneous report. Keep in mind that the report may be critical, and time may be of the essence. Most important, whenever an error in laboratory or diagnostic test reporting is discovered, it's essential for the laboratory or facility to retrace the handling of the specimens, films, and such to determine how erroneous results were released. The facility should then institute appropriate policy and procedure changes to prevent recurrence of such errors.

How to Fix an Electronic Mistake

Correcting errors in EHRs should follow the same basic principles as correcting paper copies.

Work with your vendor to confirm that your EHR allows error correction and determine whether the vendor has established a process.

The system must have the ability to track corrections or changes once the original entry has been entered or authenticated.

When correcting or making a change to an entry, the original entry should be viewable, the current date and time should be entered, the person making the change should be identified, and the reason for making the change should be noted.

If a hard copy has been printed from the EHR, the hard copy must also be corrected.

The process should permit the author of the error to identify, and time/date-stamp, whether the data in question really are erroneous.

The process should offer the ability to suppress viewing of the actual error but ensure that a flag exists to notify other users of the newly corrected error.

The location of the error should also point to a correction. The correction may be in a different location from the error if narrative data are involved, but a mechanism must exist to reflect the correction.

Develop a practice policy to ensure that your facility corrects and reports errors in a consistent and timely manner.

If this sounds like a hassle, it is. But it's the right thing to do for your patients, and if you should ever be sued for malpractice, your EHR can be your best friend or your worst enemy, depending on how accurately patient records are kept. So be diligent about dotting every 'i' and crossing every 't' electronically, and if you do make a mistake when entering data, or if you didn't err but the data are wrong (hey, it happens), be transparent and public about setting things right.

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