POLICY FORMAT - PROPOSED

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WOOD COUNTY HEALTH DEPARTMENT
POLICY & PROCEDURE TITLE:
EFFECTIVE DATE:
DATE REVIEWED/REVISED:
AUTHORIZED BY:
ESSENTIAL PUBLIC HEALTH SERVICE:
Correction of Errors in Health Care Record
05/2007
06/2011, 05/2012, 04/2013, 5/2014, 7/2015
Sue Kunferman, Director/Health Officer
Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.
Assure a competent public health and personal
healthcare workforce.
POLICY STATEMENT:
Wood County Health Department employees respect legal regulations related to client medical
records. Any errors in medical records will be corrected in an acceptable, ethical manner in
accordance with this policy/procedure.
OBJECTIVE:
To provide uniform guidelines for health department staff regarding correction of errors in
client medical records.
WHO PERFORMS ACTIVITIES (JOB TITLES):
All staff creating client records or documenting services.
PROCEDURE:
The following guidelines will be followed by all health department staff when correcting errors
in client medical records:
 Correction fluid/tape will not be used under any circumstance.
 Word correction: draw one line through the incorrect word or phrase, initial by it, and
write in the correct word or phrase above it.
 Extra words: draw one line through the word, initial by it, and write “error” above it.
 If several lines are incorrect, cross them out with one line, initial near it and write
“error” by the incorrect lines.
 Late entry: write “late entry” in the left hand column, write in the date and time the
entry is actually made, and document the narrative of the late entry. Sign the entry at
the end.
 Specific situations not addressed above will be discussed with the health department
director.
Correction of Errors in Health Care Record Page 1
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