3.01.02 Amended PCRs

3.01.02 Amended PCRs  (Revised 10/2020)

OVERVIEW

Addendums or corrections to patient care reports such as narratives, vitals, and/or scales are sometimes necessary but should be minimal. Altered records must be valid, traceable, dated and signed by the person making the addition or change. Electronic records amendments must begin with “//” and end with the name of crew member amending and date of amendment followed by “//”. A reason for the amendment must be included and should come at the very bottom of the narrative, identified as such: **Reason for amendment: ** There should be an audit trail accessible in the software for all electronic record access.

Paper record amendments must be clearly documented either on the original document or by a supplemental amendment document. Changes to written documents should be scored out with a single line with the original writing visible and initialed.  The original writing must be visible and the new information should be signed with date and time.

With the exception of demographic changes, all addenda or corrections should be made by a member of the treating crew.  Transcription of changes may be provided by supervisory or compliance personnel only in approved circumstances.

 SECTION A

Addendum

Addendum: An addendum is used to provide information that was not available at the time of the original entry. The addendum should also be timely and bear the current date and reason for the addition or clarification of information being added to the medical record and be signed by the person making the addendum.