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When corrections are being made to medical records should they be date and time stamped?

  • Proper procedure indicates that yes -- it usually should be. Corrections in insignificant things such as spelling are of course less critical, but anything emergent to timely needs to show when the noted changed was detected. Likewise, I suggest that the change is initialed.

    Note also that corrections never ever eradicate what was erroneously there before. The old entry is single-line struck out and the correction added. The exception to this is corrections asked for by the patient and made by the doctor, under the HIPAA guidelines.

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