Correcting and amending a clinical note

You can correct a treatment note you have just written, and you can add to one at any time afterwards. They are two different things on purpose.

Same day: edit it

For 24 hours after a note is written, open the record and press Edit. Change what you need and save. A correction made an hour, or a morning, after writing is still a contemporaneous record, which is why it is a plain edit rather than anything more formal.

Every change is recorded. The record shows an Edit history listing who changed it and when, so nothing is lost and nobody has to take your word for it.

After that: amend it

Once a note is more than 24 hours old, or once it has been signed off, Add amendment replaces the Edit button. An amendment is a new dated, attributed entry that appears underneath the original. The original stays exactly as it was written.

Use it for anything that comes in later: a phone call the next morning, a result, a detail the patient remembered afterwards, or a correction you have only just spotted.

Why it works that way

A clinical record is a narrative, not a document that shows the current position. It answers "what was known, and when". A note edited a fortnight later answers only "what is believed now", and the original is gone from the record even though a copy survives in the audit trail.

If the record is ever disclosed, to a patient, an insurer, a regulator or a court, it needs to read in order and show its own amendments. That is why paper practice has always used the dated addendum rather than the crossing-out, and it is the same reasoning here. A record you can quietly rewrite is worth much less than one you cannot.

Reading the trail

Open any record to see its edit history, if it has one. Amendments sit indented underneath the note they amend, oldest first, so the whole thing reads forward.

Records brought in from a previous system show their history as imported rather than naming a person. That is accurate: those changes were made by the migration, not by anyone at your clinic.