In case of documentation correction, what additional step is often required?

When corrections are made to documentation, it is essential to enter a note explaining the corrections. This practice serves several important functions. It provides a clear record of what changes were made, the reason for those changes, and helps maintain the integrity of the medical record. This transparency is crucial for legal and procedural reasons, ensuring that any reviewers can understand the rationale behind any modifications.

Using a note to document corrections also helps to maintain continuity of care by informing other healthcare professionals involved in the patient's treatment about changes that might affect clinical decisions. It clarifies the context, making it easier for anyone reviewing the documentation to follow the patient’s journey and understand their current status based on accurate records.