How should conflicting information in a medical record be resolved?

To effectively resolve conflicting information in a medical record, querying the provider and creating an addendum or late entry is essential. This approach ensures that all parties involved in the patient's care have clarity and that the documentation reflects accurate and complete information.

When conflicting information arises, it is vital to consult the original source — in this case, the provider. By querying them, you can obtain clarification or an explanation regarding the discrepancies. Following this, the use of an addendum or late entry allows for the documentation to accurately reflect the provider's intent or additional insights. This maintains the integrity of the medical record and supports continuity of care.

Creating a new documentation piece or merely deleting conflicting information can lead to potential gaps in the medical record, misrepresent the patient's medical history, and result in compliance issues. In contrast, addressing the conflict through targeted communication and supplemental documentation upholds the principles of accurate medical record-keeping. This is crucial not only for the quality of patient care but also for purposes such as risk adjustment and regulatory compliance.