Name: ________________________________________
Date: _________________________________________
Procedure 13-2:
Correcting an Entry in the Electronic Health Record
Objective: Correct an entry in the electronic health record in an accurate manner following legal
protocol.
Equipment and Supplies: Computer with electronic health record software
Affective Behaviors: Affective behaviors provide a professional approach to a skill that enhances
the patient encounter. These behaviors may also display sensitivity to a patient’s rights and
enhance communication. Pay close attention to these skills, which will be in bold, italicized font.
Skills Assessment Requirements
Read and familiarize yourself with the procedure. Complete each procedure within a reasonable
amount of time, with a minimum of 85% accuracy.
Documentation
Use the area below for any documentation needed to complete the procedure.
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GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. Log in with your assigned user
identification name and the
password you previously created.
2. Identify the correct patient EHR in
which the error was made.
3. Locate the error within the record.
4. Review the rules associated
with the software you are using
for correcting or making an
addendum to a patient’s record.
5. Make the appropriate correction
within the medical record,
according to the steps required
within the software program.
6. Complete the signature process,
according to the steps required
within the software program.
7. Verify that the change made is
correct and reflects the change
you intended.
8. Save the changes.
9. Close the patient’s electronic
health record.
10. Log o the system.
GRADING
Points Earned
Points Possible 72 72
Percent Grade (Points Earned/
Points Possible)
PASS: YES
NO
N/A
YES
NO
N/A
Instructor Sign-O
Instructor: ______________________________________________ Date: _________________________
POINT VALUE
= 3–6 points
= 7–9 points
Name: ________________________________________
Date: _________________________________________
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click to sign
signature
click to edit
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