Adding Addendums On Locked Chart Notes
Did you or another provider in your group make a chart note in the wrong client account?
Did you make a mistake on a specific portion of the chart note that you locked and want to clarify?
Read on to learn more about adding a handy Addendum to any locked chart note!
Note: if you charted on the wrong client or wrong appointment (or simply wish to fully start over), we suggest reviewing this article for a complete redaction: Charting Redactions
Addendum Information
Key Notes:
- Once any chart note is finalized and locked, it cannot be edited or fully removed.
- This is common practice for medical records: an entry cannot be removed once signed (and locking is the electronic equivalent of signing) per our understanding of HIPAA
- Adding an addendum does not remove any of the original chart note
- An addendum is added to the end of the original chart note
To add an addendum, you have two options:
From the Schedule:
calendar_today Note: The appointment must already be charted & locked before an addendum can be added.
- Click Calendar (left menu)
- Click on the appointment, loading the popup
- Near the top right click the shown below:
- At the top you'll see the chart entry you're making the addendum to
- Beneath the chart entry find the Addendum section
- Enter the details of your addendum in the notes field shown below
Text Editor Options:
- Text sizes → from heading 1-6 and normal text
- Formatting → bold, italic, underline, and small text
- Additionally → bullet points, numbered bullet points, and paragraph indentations
- When done, click (bottom right):
task_alt Congratulations! Your addendum has been added to this chart note and is now a part of the clinical record.
From the Records Tab:
calendar_today Note: The appointment must already be charted & locked before an addendum can be added.
- Click (left menu)
- Click on the client's name, loading their profile
- Click Records (top tab)
- Find the appointment (in chronological order) on the page
- Beneath the chart entry, at the bottom right click
- At the top you'll see the chart entry you're making the addendum to
- Beneath the chart entry find the Addendum section
- Enter the details of your addendum in the notes field shown below
Text Editor Options:
- Text sizes → from heading 1-6 and normal text
- Formatting → bold, italic, underline, and small text
- Additionally → bullet points, numbered bullet points, and paragraph indentations
- When done, click (bottom right):
task_alt Congratulations! Your addendum has been added to this chart note and is now a part of the clinical record.