Document Error States
Every entry in SystmOne exists in a defined state. The system is designed so that documentation never truly disappears — corrections add to the audit story rather than erasing it.
This page information supports: ISO 9001 10.2 ISO 27001 9.4.5 / 12.4 ISO 27789 ISO 18308
Document states are the mechanism that lets us correct errors safely while preserving a complete audit trail.
The Four States
Active
Current, valid, clinically relevant entries actively used for patient care decisions. Visible to authorized users, included in reports, and contributes to clinical decision-making. Most documentation remains Active unless an error is identified.
Error-marked
Incorrect documentation flagged using Mark in Error, preserved for audit. Visually struck through, remains visible but clearly identified as erroneous, and cannot be edited once marked. The reason for marking and full audit trail are permanently recorded. Excluded from reports and active clinical data.
Deleted
Documentation removed from standard views and stored in the Deleted Items node, visible only to users with specific permissions. Complete metadata is preserved (who deleted, when, why). Some items can potentially be reinstated if deleted in error.
Sealed
Entry is locked and access is restricted to authorised roles only. Used for sensitive or completed records. Sealed entries cannot be edited or marked in error through standard workflows — any access or action is logged with a full audit trail.
When You Discover an Error ⚠️
Follow this process when you identify or make a documentation error:
Do not conceal it
Transparency is required. Errors hidden today become safety risks tomorrow.
Assess patient impact
Does the error affect current care decisions? If yes, escalate immediately to your supervisor.
Mark it correctly
Use Mark in Error↴ for incorrect entries. When you mark an entry in error, the system moves it to the Deleted Items node and asks for a reason. The original entry remains auditable but no longer contributes to active care decisions.
Document the correction
Add a clear explanation of what was wrong and why. This supports the Audit & Monitoring ↴ Implementation process.
Notify relevant parties
Inform your supervisor for critical errors. For cross-organisation entries, use the request workflow.
Need help?
See How to Mark an Entry in Error↴ for step-by-step instructions, or Correction Workflows↴ for complex scenarios.
Categories of Non-Conformity
Documentation errors fall into three categories:
| Category | Examples |
|---|---|
| Administrative | Wrong demographics, duplicate records, incorrect appointment details |
| Clinical | Wrong patient record, incorrect SNOMED code, wrong medication dose, missing critical info |
| Procedural | Wrong template used, procedure not documented, bypassing mandatory fields |
Why This Matters
| For | Purpose |
|---|---|
| Clinical staff | Recognize when documentation is in error and should not be relied upon |
| Supervisors | Audit documentation quality and error patterns |
| Governance | Support medicolegal defence and demonstrate compliance |
| Patient safety | Prevent decisions based on erroneous data |
- Every document exists in one of four states: Active, Error-marked, Deleted, or Sealed
- Nothing is truly deleted — documentation is preserved with complete audit trails
- Error-marking is permanent and cannot be reversed (though reinstatement may create a new active entry)
- State transitions support ISO 9001 10.2 and ISO 27001 9.4.5 / 12.4 expectations for integrity and auditability
- Complete, unmodifiable audit for every state transition ISO 27789 ISO 18308
Contributor
Dr Fuad Jaafar
Facilitator, CCMS • KK Bandar Maharani