There are situations when it is necessary for a veterinarian to change a medical record to ensure that the correct information is recorded. Whether making a correction in electronic records or paper-based records, a veterinarian must not delete or make the original information illegible when making a correction.
Paper-based Records: Corrections should be documented with the date of the change, the initials/name of the person making the change and a notation explaining the reason for the change. It is sufficient to strike a single line through incorrect information in paperbased records. The original information must remain legible.
Electronic Records: Electronic records should establish an audit trail that documents the change and retains the original information. A veterinarian must be familiar with the auditing capabilities of their software system, for example:
Some systems have an on/off feature for preserving the original content of records.
Other systems have a time-out feature or locking feature – this feature can be set so the system will time-out after a period of inactivity. The veterinarian must then sign back into the system to make the next entry.
If a software system does not have auditing capabilities, then a correction to the record can be documented as an addendum with the date of the change, the initials/name of the person making the change, reference to the entry being modified, and a notation explaining the reason for the change.
While some systems maintain an audit trail external to the main record, it is still considered part of the record. When making copies of electronic records, the audit trail must be accessible and capable of being printed.