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An update is current information entered in place of existing data. Data meant to be frequently updated is considered transient.
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Administrative correction is corrective action by administrative personnel with the authority to correct health information previously captured by or in error.
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Addendum is the inclusion of additional information to the source document.
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Amendment is alteration of health information by modification, correction, addition, or deletion. Any data contained in IHS patient records may be amended by request.
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Addenda clarify information in the source document by adding details or information that was omitted from the original document.
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An addendum is not initiated by the patient.
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Amendment/Correction requests must be submitted in writing by the patient, stating explicitly what information is in dispute and why; inaccurate, erroneous, irrelevant, untimely, or incomplete.
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Addresses a dispute a patient has about information in the patient's permanent record.
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Examples:
Solicitations from mail outs, registration activities, means test requirements, etc.
An address change
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Examples:
Progress note entered on wrong patient's chart.
Placing lab value in the wrong record.
Transaction typing the wrong word or diagnosis.
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Examples:
An attending adds information on the physical exam omitted by the Resident.
A nurse indicates education was provided, omitted from the original document.
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Examples:
Signed (legally binding) subjective comments or interpretations found in:
Progress Notes
Discharge Summary
History and Physical
Autopsy
Consult Note
Comments
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