Which term describes the addition of omitted information to an entry that has already been signed?

Which term describes the addition of omitted information to an entry that has already been signed?

• A. Late entry
• B. Addendum
• C. Amendment
• D. Erratum

Answer: (A)

When you need to include information that was omitted after a chart entry has already been signed, the term used is a late entry. This practice preserves the original record as the authentic, time-stamped document, while still capturing important details discovered later. To do this correctly, you add a new entry with the date and time of the omission, explain what was omitted and why, and sign it to tie it to the original note. An addendum would usually accompany a document that hasn’t been signed or finalized yet, or be used to add material to a separate document. An amendment implies changing or correcting the original signed entry, which can undermine the integrity of the initial record. An erratum is typically a correction of a printed or published error, not a clinical chart entry. Therefore, the best term for adding omitted information to an already signed entry is a late entry.

When you need to include information that was omitted after a chart entry has already been signed, the term used is a late entry. This practice preserves the original record as the authentic, time-stamped document, while still capturing important details discovered later. To do this correctly, you add a new entry with the date and time of the omission, explain what was omitted and why, and sign it to tie it to the original note.

An addendum would usually accompany a document that hasn’t been signed or finalized yet, or be used to add material to a separate document. An amendment implies changing or correcting the original signed entry, which can undermine the integrity of the initial record. An erratum is typically a correction of a printed or published error, not a clinical chart entry. Therefore, the best term for adding omitted information to an already signed entry is a late entry.