Procedure
If you charted the wrong patient
When you notice an entry landed on the wrong patient, this page helps you correct both records calmly and keep a clear audit trail.
When you notice an entry landed on the wrong patient, act as soon as you see it. This page helps you correct both records calmly and keep a clear audit trail.
Corrections are additive
Corrections in Pensieve are additive. The original entry stays, marked as corrected, and your correction sits beside it, so the trail reads honestly for both patients.
Correct it at once
- 1
Confirm both patients
Open both records and confirm identity by name and identifier. Be sure which entry is wrong and where it belongs. See find a patient.
- 2
Correct the wrong record
Mark the entry on the wrong record for correction, and note the reason. The original stays, marked as corrected, so the trail holds.
- 3
Re-enter on the right record
Enter the same information on the correct patient, and confirm the save. The record holds it with your name and the time.
- 4
Tell the people it touches
If the entry shaped a clinical decision, tell the clinician. If it raised a charge, tell the billing counter.
- 5
Record the reason
Note why you made the correction. The audit trail then reads clearly for a later reviewer.
How corrections work
| Entry type | How it is corrected |
|---|---|
| Clinical note | A correction entry sits beside the original, which stays marked as corrected. |
| Result | A new version supersedes the prior one, and the prior version stays on the record. |
| Charge | A credit note reverses the charge on the wrong account, and the charge is raised on the correct account. |
| Dose given | The correction is recorded, and the clinician is told, so care stays safe. |
What the trail keeps
Every entry names the person who made it and the moment they made it. A correction adds to that history rather than replacing it.
Both records keep a clear account. The wrong record shows the entry and its correction, and the right record shows the re-entry. A reviewer reads the full story on each.
Can I remove the wrong entry?
A correction stays additive. You mark the entry as corrected and re-enter on the right patient, so the trail stays honest for both records.
Who sees that a correction was made?
The correction carries your name and the time, and a reviewer reads it in the record's history alongside the original.
What if a charge already went to the wrong account?
In Vault, a credit note reverses the charge on the wrong account, and the charge is raised on the correct one, so both balances stay accurate. See issue a credit note.
Read how to raise it further when an entry needs a wider correction, on how to report a problem.