Amendment Policy for the Electronic Health Record

Policy: Amendment Policy for the Electronic Health Record

Effective Date: 12/10/2012

Revision Dates: 11/08/2012

Purpose: To implement a uniform process that clearly identifies amendment entry date, original date of service, and protects the original chart note or form from alteration.

axiUm Instructions for all Amendments

axiUm screen shot

Late Entry/Addendum Guidelines

  • Must be entered with the current date
  • Must include the reason for addition or clarification
  • Must reference the original documentation
  • Should only be added if person documenting has total recall of omitted information

Correction Guidelines

  • Must be entered with the current date
  • Must include the reason for correction
  • Must not alter or delete original documentation
  • Must reference the original documentation

Dean of UW SOD:

Jean Garber, Assistant Dean, Finance & Administration

December 10, 2012