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Discussion

making adendums to charting

If you realized you made a mistake in your charting, can you go back and make a correction the next day. I made a mistake regarding iv fluids infusing and forgot to put what the iv was and where it was. I made an adendum in the computer and wrote: correction iv fluids infusing from left hand peripheral iv. i originally charted left radial art line with iv fluids infusing at such and such rate. I meant to chart left hand peripheral iv and charting the left radial art line. how long do you have to make a correction?

Featured Replies

I've corrected it whenever I've remembered it. Just correct, date, time, initial. Chances are I've charted incorrectly before and NOT remembered it, so therefore haven't corrected it, lol!

  • Author

Ok, We have computer charting and you have options of undoing notes or making addendums so I chose addendums and made an entry stating correction and then charted the correct note and the correction is under the original note and the correction also has the date and time since it is computer charting.

  • Experts

I've never done computer charting and would have to advise you to follow the protocol for correcting the charting. Fascinating that you have the option to go back in and correct the original entry. How does this look when the chart is audited for some reason and the computer shows that the chart was accessed at the later time? I would think that this would be a red flag were it to come up in a lawsuit. Therefore, I would think that the requirement to do a corrected entry as an addendum would be the way to do it. I really hope I never have to do computer charting. :typing

  • Author

Yes, that is what I did. I made an addendum and the addendum shows up under the original entry but the original entry is still there.

No matter what your hospital policy, the medical record should be accurate in every way. Do a late entry with the date and time that you are entering the information and then give the date and time of the event you are charting about. Better late than never.

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