How is a Correction Made to an Electronic Health Record by an LPN?

Studies show that nearly 20% of medical errors come from record mistakes. Electronic Health Records (EHRs) hold vital details like medications, treatments, and patient history. Licensed Practical Nurses (LPNs) are key to keeping this information correct. Errors can happen, like typos, missed notes, or wrong doses.

The question is, how is a correction made to an electronic health record while staying compliant? Even programs with Illinois College of Nursing accreditation highlight why accuracy matters for safe patient care.

The Correct Process for LPNs to Make Corrections in Electronic Health Records

Accuracy in Electronic Health Records (EHRs) is critical because even small mistakes can affect patient safety. Licensed Practical Nurses (LPNs) are often the first to notice errors in documentation, and knowing the correct process for fixing them is part of their responsibility. 

So, how is a correction made to an electronic health record? The answer begins with following your facility’s rules.

Follow Facility Protocols First

Every hospital, clinic, or nursing home has its own policies for correcting EHRs. LPNs should always check these guidelines before making changes. One golden rule is never delete or overwrite past data. Instead, use the official correction tools built into the system. This ensures transparency and keeps the record legally valid.

Steps to Correct an EHR as an LPN

The process for corrections is straightforward but requires attention to detail.

1. Identify the Error Clearly

Start by spotting exactly what is wrong. It might be a wrong medication dose, an incorrect vital sign, or a missing patient history detail. Being specific helps avoid further confusion.

1. Use the EHR’s Correction Function

Most systems include tools like addendums, late entries, or special correction features. LPNs should always use these rather than trying to adjust the original entry.

1. Document the Reason for the Correction

Every change needs a note explaining why it was made. This gives context for other healthcare professionals and ensures that the record shows a complete picture.

1. Date, Time, and Sign the Correction

Always include the current date, time, and electronic signature. This step creates accountability and adds credibility to the update.

1. Avoid Unauthorized Workarounds

Never try to erase or hide earlier entries. Shortcuts may seem faster but can cause compliance issues and even legal problems if records are audited.

Compliance and Legal Considerations

Correcting an EHR is not just about fixing mistakes. It is also about staying compliant with HIPAA and your facility’s documentation policies. Every action leaves an audit trail, which shows exactly what was corrected, when it was corrected, and by whom. 

This level of transparency builds trust and ensures the record remains legally sound. LPNs should also be familiar with different types of electronic health record systems, since each platform may handle corrections in slightly different ways.

Why It Matters for LPNs

Many nursing programs, including those offering anatomy and physiology classes, teach the importance of precise recordkeeping. Documentation is more than a task; it is part of protecting patients. When LPNs follow proper steps, they help maintain safety and trust in healthcare.

So, How Are Corrections Made to an Electronic Health Record? By following protocol, using system tools, and keeping everything clear and transparent. In practice, how is a correction made to an electronic health record comes down to accuracy, accountability, and patient safety.

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Conclusion

LPNs play a vital role in keeping health records accurate and reliable. By following the right process, they help protect patients, improve care quality, and meet legal requirements. Learning the proper Steps to Correct Mistakes in an EHR ensures safety, builds trust, and strengthens the overall standard of healthcare.