What information should be redacted from medical records?
All sensitive information ranging from addresses and phone numbers to past medical histories need to be redacted. More specifically, redaction is frequently used by governments and in industries like health care and financial services to protect the vast amount of sensitive information they handle every day.
What are 3 things you should not add to a medical record?
The following is a list of items you should not include in the medical entry: Financial or health insurance information, Subjective opinions, Speculations, Blame of others or self-doubt, Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
What is the term for removing identifying information from the health record?
De-identification and anonymization are strategies that are used to remove patient identifiers in electronic health record (EHR) data.
What do you do if you make mistake in documentation?
In Brief Dont obliterate the mistaken entry. Make the correction in a way that preserves the original entry. Identify the reason for the correction. Follow facility policy when adding late information. Never alter words or numbers after youve written them. Correct mistakes promptly.
What could happen if proper patient charting is not completed?
The importance of proper documentation in nursing cannot be overstated. Failure to document a patients condition, medications administered, or anything else related to patient care can result in poor outcomes for patients, and liability issues for the facility, the physician in charge, and the nurse(s).
What do you do if you document the wrong information in the patients chart?
Change such an error as soon as it is discovered by making a single line through the incorrect entry that does not obliterate the prior entry. The physician should then sign, date, and explain why the change was made.
What needs to be redacted for HIPAA?
Protected information includes a persons name, address, geographical information, addresses, phone numbers, social security numbers, and the like. Only the state that the records come from may be identified. Specific dates must be redacted from any information shared with third parties.
Do we erase errors in the documentation of a patients healthcare?
At no time should the documentation in question be removed from the chart or obliterated in any way. The resident cannot require that the records be removed or deleted. Under HIPAA, the resident has the right to request an amendment for as long as the record(s) is maintained by the facility.
What should you do if you make a mistake in charting patient information?
Make the correction in a way that preserves the original entry. Draw a single line through the erroneous entry and write the time, date, and your name. Identify the reason for the correction. Include the rationale in your notation; for example, mistaken entry, wrong medication name written.
How are you going to correct a wrong entry in your nurses progress notes?
Draw a single line through the erroneous entry, and include your name, the time and date, and a brief explanation of the correction. Explain why the correction was made. Include the rationale in your notation; for example, mistaken entry, wrote wrong medication name.
