[Answered]: Case Study: Correcting a Charting Error (Chapter 23…

Case Study: Correcting a Charting Error (Chapter 23 The Medical Record, Documentation, and Filing) search this In the course of recording patient information in the electronic health record, the medical assistant noticed that an error was made. Describe the correct procedure for making the correction? The following information was documented in the progress note: Ms. Garcia called with complaints of right-upper quadrant abdominal pain that gets worse with eating. She has been using TUMS for relief and feels better when sitting up. Will make appointment with Dr. Anderson for tomorrow. It was determined that the pain Ms. Garcia was describing was in the left-upper quadrant, not the right as documented. The medical record will need to have an addendum noted. Describe what should be written in the addendum. With electronic health records (EHR) replacing paper records, additional considerations pertain to records management and HIPAA compliance. The HIPAA Security Rule mandates that not only the privacy of medical records but also the security of the records must be guaranteed. According to the Security Rule, describe the four core areas providers must demonstrate for compliance.