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How to Mark an Entry in Error

Quick Answer

Right-click the incorrect entry, choose Mark in Error, select a reason, and add an explanation. The entry moves to Deleted Items with the audit trail preserved.

What Problem Does This Solve?

You entered documentation on the wrong patient, used wrong SNOMED codes, prescribed the wrong medication, or made any clinical data entry mistake. This guide shows how to correctly mark entries as errors without losing the audit trail.

Before You Start

Prerequisites
  • Access to the patient record containing the error
  • Write access to the relevant clinical node (Code Journal, Observations, or Medications)
  • Understanding of what was incorrect and why
  • For cross-organization entries: you must use Request Mark in Error instead

Step-by-Step Instructions

1

Navigate to the Correct Node

Open the patient's Clinical Tree and locate where the error exists

  1. Open the patient record.
  2. In the Clinical Tree, expand the relevant section:
    • Code Journal — for wrong SNOMED codes
    • Tab Journal — for incorrect vitals or documentations
    • Medication & Prescription — for wrong prescriptions
2

Right-click the Incorrect Entry

Select the exact item that needs correction

  1. Locate the specific entry in the node list.
  2. Right-click on the entry to open the context menu.
3

Choose Mark in Error

Select this option from the context menu

  1. Click Mark in Error from the context menu.
  2. A dialog box will appear prompting for a reason.
Cannot Be Undone

Marking an entry in error is irreversible through normal workflow. The entry can only be reinstated by an administrator through the Deleted Items node.

4

Select a Reason

Choose from the dropdown or enter a custom reason

  1. In the reason dialog, select the most appropriate option from the dropdown:
    • Wrong patient
    • Incorrect code
    • Wrong medication
    • Duplicate entry
    • Data entry mistake
  2. If none apply, select Other and type a custom reason.
5

Add an Explanation and Confirm

Document what was wrong so audits are clear

  1. In the explanation field, type a brief, clear note describing:
    • What was incorrect
    • What the correct information should have been
    • Who authorized the correction (if required)
  2. Click OK to confirm.
Result
  • The entry moves to the Deleted Items section
  • The audit trail is fully preserved
  • The entry is hidden from active clinical view

Common Scenarios

ScenarioWhat to Mark
Entered notes on wrong patientThe consultation entry
Wrong SNOMED codeThe specific code in Code Journal
Wrong medication prescribedThe medication entry
Wrong vital signsThe observation entry
Duplicate documentationThe redundant journal entry

Troubleshooting

Cause: You lack write access to that node, or the entry is from another organization.

Solution:

  1. Verify you have the correct role permissions for that clinical node.
  2. If the entry is cross-organization, use Request Mark in Error instead.
  3. Contact your clinic administrator if permissions are missing.

Cause: The entry was marked in error by mistake.

Solution:

  1. Navigate to the Administrative Tree → Deleted Items node in the patient record.
  2. Locate the entry, right-click, and select Reinstate.
  3. Note that medications and consent entries typically cannot be reinstated.
Audit Record

Both the original mark-in-error and the reinstatement are logged in the audit trail.

Cause: The marked entry involved clinical risk, external communications, or shared care records.

Solution:

  1. Document the incident in the patient journal (separate from the marked entry).
  2. Inform your unit supervisor or senior clinician.
  3. Follow your clinic's incident reporting protocol if required.

Contributor

Dr Fuad Jaafar

Dr Fuad Jaafar

Facilitator, CCMS • KK Bandar Maharani

84 contributions

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