Describe the steps to take when an error is made in a patient’s health record

Part 1: Errors in Health Records

Describe the steps to take when an error is made in a patient’s health record and why a medical office assistant should disclose errors made. List the most common data errors and how to avoid them.

Part 2. Critical Thinking application

Jennifer walks behind Susan’s desk and notices that Susan is looking at the progress notes on a patient who was recently arrested for child abuse. The case has been in the newspaper and on television consistently for several weeks. Jennifer asks Susan why she has accessed that record. Susan hesitates and then says she must have entered the wrong patient ID number.

• Does Susan’s explanation sound convincing
• Who owns a patient’s medical record? Can Susan read her own chart?
• Why is Jennifer concerned about Susan looking at a patient’s record?

Does any employee at a clinic have the right to look at a patient’s electronic health record simply because the individual is a patient at that clinic? What breaches in confidentiality can occur with electronic documents and how can these be avoided?

Your office has a relaxed policy with regard to the release of information in health records. A patient asks to see his record. You know that there is information in the record regarding telephone calls from the patient’s relatives that would interfere with the family relationship. The physician is away for a week. How would you handle the matter?