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Templates are valuable tools for enhancing the efficiency of documentation, but it is essential to ensure that each template utilized incorporates all required elements, and efforts should always be made to customize the documentation of each patient encounter.
There are valid instances when correction of an erroneous entry, late entries of necessary clinical information, addendums to prior entries, or amendments to the medical record need to occur. In these instances, appropriate steps should be taken to clearly document who made the entry, when the entry was made, and why the entry was made.