Strike it out with one single line, so that the original entry remains legible. Write justification for the correction, appropriately above or beside the strike out, e.g. if the cause of the error is typographical, write ‘Typographical Error’, etc. Initial and write the date when the correction was made.
Any entry error made in written procedures shall be corrected for wrong entry as per the following steps. Strike it out with one single line, so that the original entry remains legible.
This Standard Operating Procedure is applicable for correction of all documentation error in written procedures (SOPs, Specifications, STPs, or TDs etc.) and records (Batch Manufacturing Records, Raw Data, Log Books, etc.) All Head of department or area supervisor / in-charge shall be responsible to ensure errors are corrected as per this SOP.
Under no circumstances shall any artificial correction be used to correct an error (e.g. white fluid, labels, erasers, etc.). No overwriting shall be practiced.
Proper Error Correction ProcedureDraw line through entry (thin pen line). Make sure that the inaccurate information is still legible.Initial and date the entry.State the reason for the error (i.e. in the margin or above the note if room).Document the correct information.
Filing and classification systems fall into three main types: alphabetical, numeric and alphanumeric.
The patient owns the medical record. The most frequently used follow-up method is a: a. tickler file.
The Best Organization MethodsCreate a medical records binder. You can get creative and pick any color binder you want. ... Get digital with a computer. Gather virtual records, or scan in your paper records. ... Use a traditional filing system or portable file box.
There are 5 methods of filing:Filing by Subject/Category.Filing in Alphabetical order.Filing by Numbers/Numerical order.Filing by Places/Geographical order.Filing by Dates/Chronological order.
The five basic steps for filing. Conditioning, releasing , Index and coding, Sorting, Storing and filing. Involves grouping related papers together, removing all paper clips and staples, attaching smaller papers to regular records, and fixing damaged records.
How are corrections made to the electronic health record? A new entry or addendum must be added close to the original entry with the correct information and then initialed.
Listen to pronunciation. (FAH-loh-up kayr) Care given to a patient over time after finishing treatment for a disease. Follow-up care involves regular medical checkups, which may include a physical exam, blood tests, and imaging tests.
What is the most important reason for telling the physician when a charting error is discovered later? The most important reason to report errors in the medical record is to make sure the patient's health and well-being are not jeopardized. The patient's health record should never leave the office.
CMAA REVIEWQuestionAnswerWhich of the following is a step in the annotation process?highlighting textWhich of the following methods organizes patient records in chronological order according to the department that provided the care?SOMR51 more rows
Which of the following describes the proper protocol for the release of medical records? When medical records are subpoenaed, the patient should be notified in writing. As a protection in the event of litigation, records should be kept until the applicable statute of limitations period has elapsed.
Top 3 Ways to Track and Maintain Patient Records:Integrate Patient Records.Record Medical Prescriptions Electronically.Archive Patients Record on Cloud.