Scenario 

At the end of your workday, you realize that you forgot to document that you provided one of your earlier clients with post-operative instructions for their fluoride treatment. You log back into your computer and access the client’s electronic record. What is the most appropriate way to add this information?  

Maintaining accurate records 

Keeping clear and accurate records is an important part of providing safe and professional care. Well-documented records support continuity of care and can also be helpful if questions or concerns arise about the services provided. 

Whenever possible, clinical notes should be completed at the time of the appointment or shortly afterward. There may be times when this isn’t possible, but it’s important to record information as soon as you can. When adding or updating information later, be sure the date of the entry and any additions are clearly and accurately documented. 

Relying on memory after a significant delay can make it harder to include all relevant details. Recording information promptly helps ensure notes remain complete, accurate, and useful for both client care and professional practice. 

Making additions or corrections 

Like handwritten records, electronic records should include a way to track changes through an audit trail. An audit trail shows who accessed, created, or modified a client record, and when this occurred. Features such as “locking” or “committing” notes help support this process.  

When making additions or corrections to electronic clinical notes, consider the following:  

• If the electronic note has been “locked” or “committed”, add a late entry that includes the current date, the reason for the delay and the missing information.  

• If the electronic note has not yet been “locked” or “committed” and it is still the same day as the treatment, a late entry may not be necessary. In this situation, it may be appropriate to continue documenting within the existing note, as long as it is done within a reasonable timeframe (such as a few hours after the appointment).  

• In all cases, the identity of the provider should be clearly documented.  

As a best practice, electronic entries are ideally dated, completed, and “locked” or “committed” on the same day the treatment is provided. This helps protect the integrity of the record and ensures it accurately reflects the care delivered and what occurred during the appointment. 

If you have any questions about record keeping, please get in touch with us at advice@cdho.org or by calling 1-800-268-2346 (press 2). You can also review our Record Keeping e-Learning Module.