CCMA - Administrative Assisting - Section 5.4

Maintain accurate clinical and administrative records using filing systems, chart review, and data entry best practices.

Maintain accurate clinical and administrative records through correct EHR data entry, chart documentation standards, and appropriate filing system practices. Recognise the principles of medical record ownership, amendment procedures, and the importance of timely and accurate documentation for continuity of care.

Medical recordsEHRChart documentationFiling systems

Practice question for this objective

Free sampleAdministrative Assistingeasy

While entering vital signs into the electronic health record, a medical assistant notices they typed the blood pressure as 1280 over 80 mmHg instead of 128 over 80 mmHg and has already saved the note. What is the BEST action to correct the entry?

  • AUse the EHR amendment or addendum function to enter the correct value, with a note that the prior entry was a typing error, while the original entry remains visible. Correct
  • BDelete the saved entry from the chart entirely and re-enter the correct blood pressure with the original time stamp so the record looks clean.
  • CLeave the incorrect entry in place and verbally tell the provider during the visit so the doctor remembers the right value when reviewing the chart.
  • DAsk the IT department to overwrite the field in the database so the patient's chart shows only the correct blood pressure going forward.
Apply the EHR amendment workflow to correct a data entry error while preserving the original entry and audit trail. Electronic health records are legal documents and every entry, including errors, must remain visible with a clear correction attached. Using the amendment or addendum function adds the right value, links it to the original, and stamps the change with the user identity and time, so any later reviewer can see what was originally recorded, what was corrected, by whom, and when.

Why A is correct: The EHR amendment function preserves the original entry, adds the corrected value, and stamps the change with the user and time, which is the documentation method required for electronic records and meets the legal standard for an auditable correction.

Why B is wrong: Deleting the saved entry hides that an error occurred and rewriting the original time stamp falsifies the audit trail; electronic records must retain the original entry and show every change with its own time stamp.

Why C is wrong: Verbal handoff does not correct the written record, and a future clinician opening the chart will still see 1280 over 80 mmHg, which is clinically impossible and could trigger a wrong treatment decision.

Why D is wrong: Database overwrites bypass the audit trail and are treated as record tampering; corrections must be made through the EHR's user-facing amendment workflow, not by editing stored data directly.

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