A major component to the Health Information Management (HIM) is mainly handling of the amendments, deletions and corrections. The management of this does not change too much when dealing with Electronic Health Records (HER) (Terri, Keith, Anne, 2009).
There are several situations where information has been altered either knowingly or unknowingly thus warranting an alteration. The problem with this is that there might be very little distinction between an original and an edited text. The edited text often occurs with very minimal versioning or even track-changes functionality. The alterations are normally done by use of addendums which is a new documentation that is often used to add or delete any information to an original entry (Terri et al2009).
The following scenario presents a situation which warranted patient’s information alteration and thus correction had to be made. A patient went to the outpatient department in order to have an x-ray of the chest done as well as the sputum culture. The patient was then referred from a primary care physician onto a long-term cough. The resident physician interpreted the x-ray and stated that it was pneumonia and then signed the report. After seven days, the sputum culture results indicated that the patient had streptococcal infection. The resident physician then returned to the original note and completed the addendum so as to indicate the infection. This scenario raised two concerns. First of all, the original report had originally been final signed by the provider. Secondly, the information added changed the information that was already within the EHR. This new information actually has the ability to affect the treatment that the patient will receive.
To handle this case effectively, the new added information was connected to the original information and then the original and the addendum was signed by the provider. This is because the addendum was providing an additional information to the original document that was signed before. For this additional information to have meaning, it was connected to the original report(Terri et al2009).
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