The following report was phone in and charted: "05/14/12-Urinalysis reveals RBC too numerous to count." When...
The following report was phone in and charted: "05/14/12-Urinalysis reveals RBC too numerous to count." When the written report is received, you note it as WBC, not RBC. How would you make this correction in a paper record? How would it be made in an EMR?
Homework Answers
Answer: Whenever there is an error in the medical record into the case of paper records it is important to follow the rules to make correction instantly as soon as the error has been find. In the paper record, the correctuon is made as by drawing a thin line to the column and correction is made. The error should not be cut or removed but under the heading of correction, the correct record should be mention along with the reason of the correction.
In the case of EMR, the same procedure is performed on the system. It involves the entry of the correct code, reason of the error as well as update the information.
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The following report was phone in and charted:
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