Documentation Correction Workflows

SystmOne provides multiple correction workflows designed for specific error types. Understanding which workflow to use ensures accurate corrections while maintaining audit trail integrity.

Overview of Correction Workflows

This page provides a comprehensive overview of all correction methods available at KKBM, with clear guidance on when to use each one.

KKBM recognizes eight correction workflows covering the most common error scenarios encountered in clinical practice:

1. Mark in Error

Primary Function

Hide incorrect documentation while preserving audit trail

When to Use

Documentation on wrong patient, incorrect clinical notes, wrong SNOMED codes, mistaken entries

2. Registration-Based Corrections

Primary Function

Correct patient demographics and identity information

Covers

Duplicate records, wrong IC numbers, incorrect name/DOB/gender/address

3. Vaccination Entry Correction

Primary Function

Correct vaccination records with wrong batch/part number

Process

Mark incorrect entry in error, create new entry with correct vaccine details

4. Medication Prescription Error

Primary Function

Correct prescription errors before dispensing

Covers

Wrong drug, dose, route, frequency, or patient

5. Appointment Detail Correction

Primary Function

Fix appointment scheduling errors

Covers

Wrong date/time, wrong clinic/service, duplicate bookings

6. Patient Reallocation

Primary Function

Move patient to correct room or service

When to Use

Wrong room allocation, incorrect service assignment

7. Test/Procedure Order Correction

Primary Function

Cancel and replace incorrect investigation orders

Covers

Wrong lab test, wrong radiology request, duplicate orders

8. Manual Late Entry

Primary Function

Document missed or delayed entries with proper dating

When to Use

Missed documentation, post-downtime entry, late phone consultations

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Correction Workflow Details

3.1 Workflow #1: Mark in Error

Primary Function: Hide incorrect documentation while preserving audit trail

When to Use:

• Documentation entered on wrong patient record
• Incorrect clinical notes or observations
• Wrong SNOMED codes selected
• Mistaken medication entries
• Any data entry error that needs correction

Key Features:

• Most frequently used correction method
• Crosses out entries but keeps them visible in audit trail
• Requires reason for marking in error
• Can be reversed through "Reinstate" function
• Works across most nodes (consultations, vitals, prescriptions)

Link: → See A.4.6.2 Mark in Error Function for complete details

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3.2 Workflow #2: Registration-Based Corrections

Primary Function: Correct patient demographics and identity information

Three Sub-Types:

Correction Type	When to Use
Merge Duplicate Records	Same patient registered twice under different IC or name
IC Number Correction (Security Controlled)	Child registered under mother's IC, incorrect IC number entered
Demographic Detail Amendment	Wrong name, DOB, gender, ethnicity, address, or phone number

Critical Note: IC number changes and record merging are security-controlled procedures. Always verify patient identity before proceeding.

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3.3 Workflow #3: Vaccination Entry Correction

Primary Function: Correct vaccination records with wrong batch/part number

When to Use:

• Wrong vaccine batch number entered
• Incorrect vaccine part number
• Wrong vaccine type recorded
• Vaccination entered on wrong patient

Standard Process:

Mark incorrect entry in error, then create new correct entry with proper vaccine details.

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3.4 Workflow #4: Medication Prescription Error

Primary Function: Correct prescription errors before dispensing

Common Scenarios:

• Wrong drug prescribed
• Incorrect dose, frequency, or formulation
• Wrong route of administration
• Prescription on wrong patient record
• Duplicate repeat prescriptions

Critical Workflow:

Involves coordination between doctor and pharmacist. Pharmacist identifies error during vetting, communicates with prescriber, prescription is marked in error, and new correct prescription is issued.

Patient Safety Note: Never allow incorrect prescriptions to be dispensed. Always verify before medication reaches patient.

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3.5 Workflow #5: Appointment Detail Correction

Primary Function: Fix appointment scheduling errors

When to Use:

• Wrong appointment date or time
• Patient booked into wrong clinic/service
• Appointment on wrong patient record
• Duplicate appointment bookings

Error Type	Correction Action
Wrong Date/Time	Use "Move Appointment" function to reschedule
Wrong Clinic/Service	Delete appointment and book new one in correct rota
Wrong Patient/Duplicate	Delete appointment with cancellation reason

Best Practice: Always notify patient of appointment changes.

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3.6 Workflow #6: Patient Reallocation

Primary Function: Move patient to correct room or service

When to Use:

• Patient auto-allocated to wrong room
• Patient manually assigned to incorrect consultation room
• Wrong service type selected during registration

Quick Method:

From patient record → Clinical Tree → Appointments Node → Right-click incorrect appointment → Administration → Delete → Rebook to correct room/service.

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3.7 Workflow #7: Test/Procedure Order Correction

Primary Function: Cancel and replace incorrect investigation orders

When to Use:

• Wrong lab test ordered (e.g., LFT instead of FBC)
• Wrong radiology request (e.g., Chest X-ray instead of Abdomen X-ray)
• Test ordered on wrong patient record
• Duplicate test/procedure orders

Two-Stage Process:

Stage	Action
Before Processing	Clinician deletes order from patient record (Clinical Tree → Order Requests → Right-click → Delete)
After Processing	Lab/Radiology technician rejects order from Order Request Overview module

Important: Always re-enter correct order after cancellation.

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3.8 Workflow #8: Manual Late Entry with Justification

Primary Function: Document missed or delayed entries with proper dating

When to Use:

• Documentation missed during actual encounter
• Data re-entry after system downtime
• Recording procedures done but not documented
• Late recording of phone consultations or advice

Three Methods Available:

Event Details Button (Toolbar): Set actual event date/time before entering documentation

Backdating Within Templates: Use date picker in templates to set actual care date

Amend Existing Entry Date: Right-click entry date → Amend Details → Amend Date (requires "Amend Consultations" access)

Critical Requirement: Always document reason for late entry in patient notes. Audit trail will show who made the amendment and when.

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4. Quick Decision Guide: Which Workflow to Use?

Use this decision table to quickly identify the correct workflow for your situation:

If Error Involves...	Use This Workflow	Reference
Clinical notes, observations, SNOMED codes	Mark in Error	A.4.6.2
Patient demographics or identity	Registration-Based Corrections	See Section 3.2
Vaccination records	Vaccination Entry Correction	See Section 3.3
Prescriptions	Medication Prescription Error	See Section 3.4
Appointment scheduling	Appointment Detail Correction	See Section 3.5
Room or service allocation	Patient Reallocation	See Section 3.6
Lab/radiology orders	Test/Procedure Order Correction	See Section 3.7
Missed or delayed documentation	Manual Late Entry	See Section 3.8

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5. Common Mistakes to Avoid

Wrong Approach	Correct Approach
Using free text to "explain away" an error without proper correction	Use appropriate correction workflow and document in audit trail
Deleting entries completely instead of marking in error	Always mark in error to preserve audit trail
Ignoring prescription errors during dispensing	Stop dispensing, contact prescriber, correct before releasing
Creating new patient record when duplicate exists	Search thoroughly and merge duplicates
Making demographic changes without security controls	Use proper security-controlled procedures for IC changes
Backdating without documenting reason	Always explain why entry is late in patient notes
Correcting others' work without authorization	Use task system or request mark in error from owning organization

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6. Before You Correct: Quick Checklist

Before proceeding with any correction, verify these essential points:

☐ Confirm Patient Identity: Verify you have the correct patient record open

☐ Identify Error Type: Determine exactly what needs correction

☐ Choose Correct Workflow: Select appropriate method from this guide

☐ Check Access Permissions: Ensure you have authority to make this correction

☐ Document Reason: Prepare clear explanation for audit trail

☐ Consider Patient Safety: Assess if error poses immediate risk requiring escalation

☐ Plan Communication: Determine if supervisor, patient, or other staff need notification

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7. Correction Workflow Implementation at KKBM

Current implementation status of correction workflows at Klinik Kesihatan Bandar Maharani:

Correction Workflow	Status	Notes
Mark in Error	Active	Frequently used by doctors and nurses for daily corrections
Registration-Based Corrections	Active	Merge and IC correction procedures established
Vaccination Entry Correction	Active	Standard practice in MCH unit
Medication Prescription Error	In Progress	Pharmacist-doctor communication protocol being refined
Appointment Detail Correction	Active	Used daily at appointment counter and clinical areas
Patient Reallocation	Partial	Staff aware but some auto-allocation issues persist
Test/Procedure Order Correction	Active	Lab rejection workflow operational
Manual Late Entry	In Progress	Event Details function available but inconsistently used

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8. Key Takeaways

• Eight correction workflows cover most common error scenarios at KKBM
• Mark in Error is the primary correction method for clinical documentation errors
• Registration-based corrections handle patient identity and demographic issues
• Each workflow preserves audit trail and maintains data integrity
• Always choose the correct workflow for your specific error type
• Document reasons for all corrections to support accountability
• When uncertain, consult supervisor or clinic administrator before proceeding
• Patient safety takes priority—escalate critical errors immediately

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Best Practices for Correction Workflows

For All Staff

Always verify patient identity before making corrections

Choose the correct workflow—wrong method can create audit problems

Document clear reasons for every correction

Double-check your correction before finalizing

Inform supervisor of significant corrections

When in doubt, ask before proceeding

For Clinical Staff

Use Mark in Error for most clinical documentation errors

Never ignore medication errors—correct immediately before dispensing

Document late entries using Event Details function

Coordinate with pharmacist for prescription corrections

For Registration Staff

Search thoroughly before creating new registrations

Merge duplicates as soon as identified

Use security-controlled procedures for IC changes

Verify demographic details with patient before saving

For Supervisors

Review Deleted Items node periodically for unusual patterns

Ensure staff understand which workflow to use for different errors

Monitor high-frequency correction areas for training opportunities

Escalate system-level correction issues to IT or clinic administrator