Addendum to Medical Records
When the physician documentation is not substantial enough to support medical necessity of a device, can the doctor make changes to the notes?
When the physician documentation is not substantial enough to support medical necessity of a device, can the doctor make changes to the notes?
The initial answer would be "yes," but with caution. Physicians may make changes to their progress notes if the physician is clarifying, expanding, or correcting information that was obtained during the evaluation. Chapter 3 of the Program Integrity Manual, Section 3.3.2.5, allows for the addition of amended, corrected or late entries by the physician. The manual says "Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. The purpose of the amendment is to correct documentation about a service that was provided during the evaluation. If the original progress note fails to make any mention of the service, the addition of the amendment may be suspect and may not be given much weight or credibility. Amendments or delayed entries to paper records must be clearly signed and dated upon entry into the record.