Certified Inpatient Coding (CIC) Practice Exam

What steps should a provider take to correct an entry in the electronic medical record?

1. Erase the incorrect entry and replace it with correct information

2. Write a signed and dated addendum to the record

3. Nothing, records should never be changed

4. Delete the wrong information and write an amendment

The correct answer is: Write a signed and dated addendum to the record

When correcting an entry in an electronic medical record, it's essential to maintain the integrity and accuracy of the medical documentation while complying with legal and regulatory standards. Writing a signed and dated addendum to the record is a best practice because it ensures that the original entry remains unchanged for legal and medical reasons. This approach provides a clear audit trail that indicates what information was originally recorded and what the correction is, thereby preserving the historical context of the patient's medical information. Creating an addendum allows for transparency, as it communicates to anyone reviewing the record that a modification has occurred, along with the rationale for that change. It is crucial in healthcare settings to maintain a complete and thorough medical record, as this can have implications for patient care, reimbursement, and legal accountability. In contrast, simply erasing or deleting incorrect entries can lead to confusion and uncertainty, as it would obscure the original documentation. Moreover, doing nothing contradicts best practices in clinical documentation, as maintaining accurate and updated records is a fundamental responsibility of healthcare providers.