I get lots of questions on how to fix provider documentation that is lacking information. Late entries, addendums, or corrections are all legitimate occurrences.
Late Entry: A late entry supplies additional information that was omitted from the original entry. It is written only if the person documenting has total recall of the omitted information and signs the late entry.
Addendum: An addendum is used to provide information that was not available at the time of the original entry.
Correction: When making a correction to the medical record, it is important to never write over or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, making sure that the original entry is legible. Correction of electronic records should follow the same principles of tracking both the original entry and the correction with the current date, time, reason for the change and initials of person making the correction.
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)
By Sean M. Weiss, Partner, Vice President, and Chief Compliance Officer
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.
What to do next…
- If you need help with an audit appeal or regulatory compliance concern, contact us at (800) 635-4040 or via email at [email protected].
- Read more about our: Total Compliance Solution
Why do thousands of providers trust DoctorsManagement to help improve their compliance programs and the health of their business?
Experienced compliance professionals. Our compliance services are structured by a chief compliance officer and supported by a team that includes physicians, attorneys and a team of experienced auditors. The team has many decades of combined experience helping protect the interests of physicians and the organizations they serve.
Quality of coders and auditors. Our US-based auditors receive ongoing training and support from our education division, NAMAS (National Alliance of Medical Auditing Specialists). All team members possess over 15 years of experience and hold both the Certified Professional Coder (CPC®) as well as the Certified Professional Medical Auditor (CPMA®) credentials.
Proprietary risk-assessment technology – our auditing team uses ComplianceRiskAnalyzer(CRA)®, a sophisticated analytics solution that assesses critical risk areas. It enables our auditors to precisely select encounters that pose the greatest risk of triggering an audit so that they can be reviewed and the risk can be mitigated.
Synergy – DoctorsManagement is a full-service healthcare consultancy firm. The many departments within our firm work together to help clients rise above the complexities faced by today’s healthcare professionals. As a result, you receive quality solutions from a team of individuals who are current on every aspect of the business of medicine.
