An Electronic Health Record (EHR) is a digital version of a patient’s medical history, containing everything from diagnoses and medications to lab results and treatment plans. This comprehensive data must be readily available to authorized healthcare providers to ensure the safest and most effective care. The integrity of this information is paramount, as an incorrect entry in the EHR can lead to misdiagnosis or a harmful treatment plan. Because patient safety and the continuity of care depend heavily on data accuracy, a standardized process for correcting errors in these digital records is necessary.
The Critical Difference Between Amending and Deleting
In an EHR environment, the physical deletion of a clinical data entry once it has been saved and signed is generally not permitted. Eliminating information entirely conflicts with the requirement for a complete, chronological record that maintains the full context of patient care.
Instead of deletion, the standard practice for rectifying an error is through an amendment, also known as an addendum or correction. An amendment does not erase the original, incorrect entry; rather, the original entry remains visible but is flagged as erroneous. The correction itself is a new entry that is electronically linked to the original, providing the corrected information. This new entry must be dated, timed, and electronically signed by the person making the change, clearly indicating the reason for the amendment.
This mechanism ensures that the complete history of documentation, including the error and its correction, is preserved. Maintaining the original information, even if incorrect, is essential for historical accuracy and may be required for legal purposes. The system must allow users to view both the original data and the corrected version to maintain a clear clinical and administrative picture.
Formal Steps for Requesting a Correction
The procedure for initiating a change to an Electronic Health Record is a formal, administrative process guided by federal rules, such as those established by the Health Insurance Portability and Accountability Act (HIPAA). Whether a patient or a provider identifies an error, the first step is to precisely identify the inaccurate or incomplete information, noting the specific date, time, and location within the record. This level of detail ensures the request can be processed efficiently.
The next administrative action is to contact the healthcare provider’s Health Information Management (HIM) department or the Privacy Office. These departments manage the designated record set and are responsible for handling all requests for amendment. A formal Request for Amendment form must typically be submitted, often in writing, which requires the individual to state the reason they believe the information is incorrect or incomplete.
The healthcare organization is required to act on the request for an amendment within a specific timeframe. Under HIPAA regulations, the covered entity must process the request and notify the patient of its decision no later than 60 days after receiving the request. If the organization is unable to meet the 60-day deadline, they are allowed a single extension of up to 30 additional days, provided they inform the patient in writing of the delay.
If the request for amendment is accepted, the provider must make the appropriate correction by appending the new, accurate information to the record and linking it to the original entry. The patient is then notified that the amendment has been made, and the organization must make reasonable efforts to inform other entities or individuals the patient identifies as needing the corrected information. If the request is denied, the organization must provide the patient with a written denial, including the reason and information about the patient’s right to submit a statement of disagreement to be included in the record.
Why All Record Changes Require an Audit Trail
Every modification, access, or attempt to change an EHR entry is tracked by a function known as an audit trail. This is a secure, chronological, and time-stamped record of all system activities, capturing details like the user’s identity, the type of action performed, and the specific data that was accessed or altered. The audit trail is a foundational requirement for electronic health systems and is mandated by federal regulations, including HIPAA and HITECH.
One main purpose of the audit trail is to ensure legal compliance and provide accountability for the institution. It serves as a verifiable history that can be used to demonstrate adherence to privacy and security rules, preventing fraudulent or unauthorized changes to patient data. The audit log can be reviewed to investigate any instance of inappropriate access to a patient’s protected health information.
The second reason is to safeguard patient safety by maintaining data integrity. By documenting the full context of care, including errors and subsequent corrections, the audit trail ensures that the entire clinical picture is transparent for providers. This comprehensive record helps to maintain the reliability of the EHR and supports informed decision-making.