Amended and Corrected Medical Records
All medical record entries need to follow standard and widely accepted record keeping principles. Occasionally, it is necessary to correct, amend or update the original medical record. In this case, the standard record keeping principles require:
- Clearly and permanently identify any amendment, correction or delayed entry clearly
are permanently identify, and - Clearly indicate the date and author of any amendment, correction, or delayed
entry, and - Clearly identify all original content, without deletion.
An amendment, also known as addendum, is used to provide information that was not readily available at the time of the original medical record entry. An amendment must be identified as an amendment, dated the current date, and signed by the person making the amendment.
Example: “This is an amendment to the note of February 1, 2021. The physical therapy report was reviewed, which indicates the patient is making progress in rehab.” Jane Johnson, M.D. February 21 2021.
When a medical record needs to be corrected, the clinician should draw a single line through the incorrect information, sign/initial and date the deletion, stating the reason for deletion in the margin. Then the correct information must be documented with the current date, making reference back to original entry.
Example: “February 1, 2021 entry included incorrect birthdate of patient. The correct birthdate is March 17, 1975.”
A late entry allows for information that was omitted from the original medical record entry. The late entry is dated with the current date, is added as quickly as possible after the original entry and is signed /dated by the practitioner.
Example: February 1, 2021. A late entry to medical record dated Jan 7, 2021. The patient exhibits signs of fatigue….” Joaquin Jones, M.D.
What Does This Mean for You?
The best practice is to always get documentation and corroborating documentation prior to claims submission. Review the documentation for completeness. If there is a need for updating, follow the standard record keeping principles. Additional information is available in the Medicare Program Integrity Manual, Chapter 3.