A Step-by-Step Guide for Healthcare Professionals and Administrators
Mistakes in medical documentation can happen—even in digital systems. Whether it’s a wrong date, incorrect medication dosage, or patient misidentification, correcting an electronic health record (EHR) properly is essential for both patient safety and legal compliance.
So, how is a correction made to an electronic health record? The answer isn’t as simple as just deleting the error. Under the Health Insurance Portability and Accountability Act (HIPAA), there are strict protocols for making changes to health records. This post outlines the correct way to update EHRs while maintaining full legal compliance and transparency.
Why EHR Corrections Must Follow Strict Protocols
EHRs are legal documents. Every note, entry, and update contributes to the continuity of patient care, and altering these records improperly can lead to legal consequences. HIPAA mandates that all amendments be documented clearly—without ever erasing or hiding original data.
According to the U.S. Department of Health and Human Services (HHS), patients also have the right to request corrections to their health records. However, it’s up to the provider to review and approve or deny the request based on clinical judgment and policy.
How Is a Correction Made to an Electronic Health Record?
Here’s a general step-by-step breakdown:
1. Identify the Error Clearly
The first step is to recognize the mistake and determine if it meets the criteria for correction. This might include:
- Misspelled patient names
- Incorrect dates of service
- Wrong lab results or entries
- Medication or dosage errors
If the issue affects care or billing, it must be corrected immediately using the appropriate EHR tools.
2. Follow Your Facility’s Amendment Policy
Most healthcare facilities have a standard operating procedure for handling EHR amendments. Consult your organization’s policy and ensure you’re authorized to make changes.
Some systems allow corrections only by those who created the entry. In other systems, designated compliance officers or health information managers may be required to approve changes.
3. Use the EHR’s Amendment or Addendum Feature
Modern EHR platforms include features that allow corrections to be added as an amendment, addendum, or correction entry. The original content remains visible but is updated with the new information.
For example, platforms like Epic or Cerner use time-stamped entries that preserve audit trails. Each change is linked to the user who made the edit, along with the reason for the correction.
As recommended by AHIMA (American Health Information Management Association), never overwrite, delete, or hide the original data—even if it’s incorrect.
4. Clearly Document the Reason for the Correction
Transparency is key. Each amendment should include a short note explaining why the correction was made, such as:
- “Corrected medication dosage from 20mg to 10mg as per updated physician order.”
- “Entered correct date of surgery—initial entry was a clerical error.”
This note builds credibility and ensures the integrity of the health record.
5. Patient-Initiated Corrections
If a patient requests a correction to their EHR:
- The provider must respond within 60 days, per HHS guidelines.
- If approved, the amendment is added to the record.
- If denied, the patient must be notified in writing with an explanation.
It’s essential to handle these requests with professionalism and ensure all correspondence is documented in the patient’s record.
What NOT to Do When Correcting an EHR
Avoid the following at all costs:
- Never delete or replace original content
- Never share login credentials to make changes
- Never backdate entries to “fix” an error
- Never leave undocumented corrections
Any of these actions could lead to legal trouble, loss of licensure, or HIPAA penalties.
Benefits of Proper EHR Correction Practices
When done correctly, updating an EHR provides several benefits:
- Maintains data integrity and compliance
- Enhances trust with patients
- Reduces malpractice risk
- Supports accurate clinical decisions and billing
These best practices aren’t just legal requirements—they’re also foundational to patient-centered care.
Correcting an electronic health record is not about covering up errors—it’s about owning them, documenting them transparently, and preserving the trust patients place in the healthcare system. The proper use of EHR correction tools and clear documentation ensures both legal compliance and clinical excellence.