Should corrections be date and time-stamped on all medical records?

Question

I am doing a report on confidentiality of computer information for a medical class that I am taking and have not found a whole lot on this subject.

Answer 1

My guess is there is a limit to error-tracking that is desireable, and perhaps even legal. For example, suppose the nurse heard me wrong, and when I said I had been addicted to amphetamines 35 years ago, she wrote down 5 years ago. Clearly this would not only make a difference to my medical history (having been clean for 35 years), but a huge difference in any possible subpena of my records due to an accident or injury more recently. If they think I was addicted 5 years ago, they are going to think maybe I still use it some.

So a note as to when that error was corrected would flag it in a way that might look like it was a cover-up, when in fact it was a correction of an error.

Medical records are not such tidy things anyway, and adding an error date and time-stamp would add a great deal of confusion. Whether it would add information it is really worthwhile to have is another matter. You would still need to distinguish between an intentional cover-up (and the incentive to falsifiy the date-stamp) versus the correction of an innocent error. So all you would have done, in my opinion, would be to further clutter up and complicate medical records, adding costs every time, to little profit.