Discussion-Health Information Services

Description

Scenario

Ms. Cherita Bell arrived for her annual well visit with Dr. Scott. As nurse Jones prepared Ms. Bell for her physical examination, she reviewed her medical history and medications. Nurse Jones noticed that according to her medical records Ms. Bell had been taking Prozac, an anti-depressant, daily for three years. When the nurse asks Ms. Bell about the medication, Ms. Bell is puzzled. ¯,4he patient says. Rve never taken Prozac in my life! I¥ never taken anything like that, and I have no idea how it got there! Please take it out of my records. nstead of deleting the medication altogether, the nurse amends the record to indicate that the previous entry was incorrect.

Why is it important to amend the record instead of deleting the medication for a complete health record?

Explanation & Answer:

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