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I often receive questions on how to handle incomplete provider documentation. Late entries, addendums, and corrections are all acceptable solutions. Documentation should be correct and accurate to ensure compliance.

When Can A Medical Record Be Changed?

To ensure that healthcare records are modified correctly, understanding the defined roles and purposes of each is vital. There are three types of modifications, each with its own significance. It’s important to define each modification to know how to apply them.

Late Entry: Any documentation that is recorded in the medical record beyond 24-48 hours of the encounter is classified as a Late Entry. This encompasses finalizing documentation, signatures, or even adding additional information that was left out from the initial entry. Late Entry documentation should only be included if the person recording it has a complete recollection of the omitted information, and signs and dates the documentation as a late entry.

Addendum: If new information becomes available after the initial entry is made, it’s possible to add an addendum. However, to ensure compliance, the addendum must be clearly marked as such, set apart from the original content, and signed and dated on the day it’s prepared.

Correction: In the world of Electronic Medical Records (EMRs), corrections are not commonly used according to guidelines. Typically, within an EMR, a “correction” is accomplished by entering edit mode. However, a correction to a medical record requires that the original content NOT be deleted, overwritten, or otherwise obliterated as the original entry. According to guidelines, the proper way to make a correction is to use a single strikethrough of the erroneous information and include the correction with your initials and the date. This ensures that the original entry remains legible and intact, but the corrected information accompanies it.

Examples of Falsifying Medical Documents

Documentation can be modified compliantly through any of these means. However, it is very important to keep in mind that deliberate falsification of medical records is a felony. Examples of falsifying records include:

  • Creation of new records when records are requested
  • Back-dating entries;
  • Post-dating entries;
  • Pre-dating entries;
  • Writing over; or
  • Adding to existing documentation (except as described in late entries, addendums and corrections)

If you have any questions regarding your team’s approach to managing provider documentation, please don’t hesitate to contact our team. We’re here to assist you in reviewing and optimizing your documentation processes.

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By Sean M. Weiss, Partner, Vice President, and Chief Compliance Officer

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Sean M. Weiss is a Partner and Chief Compliance Officer for DoctorsManagement, LLC. Sean provides strategic litigation defense services and a host of regulatory compliance services for clients nationally.

Learn more about Sean’s expertise at www.thecomplianceguy.com.

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